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

Select a time your child is happy, alert, and ready to play. Make it a game and you’ll both have fun!

The questionnaire includes questions about your child’s communication, gross and fine motor, problem solving, and personal social skills. You will be asked to answer questions about some things your child can and cannot do. This questionnaire may be provided every 2-, 4-, or 6- month period.

We look forward to your participation in our program. Please call or email us at any time if you have questions about completing the screenings or would like to discuss your child’s development. We are here to be your partner in raising a healthy, happy child.

Contact:

Melissa Vandever, Child Development Specialist

Easterseals Eastern Pennsylvania

c-mvandever@esep.org

610.289.0114 X230

MBC - WFMZ - Easterseals Eastern Pennsylvania

Child Date of Birth
Format: yyyy-mm-dd
Child DOB you entered is in the future, are you sure of that? (Please correct the date before proceeding to the next step). Please enter your child's DOB and not the screening date or today's date (Please correct the date before proceeding to the next step). Child DOB you entered is not valid, please format the date like this: YYYY-MM-DD

Weeks Premature
(put "0" if not premature)

Screening Date I am screening my child today (2021-06-15) I screened my child and am entering in the responses to a previous screening

*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.