Welcome to Easterseals Eastern PA’s ASQ-3 questionnaire.

(put "0" if not premature)

For ASQ-3™ English

For ASQ:SE-2™ English

*I have read the provided information about the MtFFC screenings.

*I wish to have my child participate in the screening and monitoring program. 

*I have received a copy of the HIPAA statement:  ESEP HIPAA

*I agree to be contacted by an Easterseals specialist, who will share the results with me and also give me activities and/or connect you to community resources in line with my child’s individual needs.

*My child’s information will only be shared with other agencies (referral for full evaluation, doctor’s, caretakers, childcare centers, community organization, etc…) with my consent, which I completed here:  ESEP Consent

Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.