Welcome Family Centers of Allentown Families! You are about to access our ASQ:SE2 Online screening program!
Weeks Premature (put "0" if not premature)
List others assisting with completion of the questionnaire
CONSENT TO SHARE MY CHILD'S INFORMATION AND FOLLOW UP:
*I have read the provided information about the MtFFC screenings. I wish to have my child participate in the screening and monitoring program. I am agreeing to the below statements, by completing the ASQ-3 and ASQ:SE-2 questionnaires.
*I hereby authorize FAMILY CENTERS OF ALLENTOWN to release and/or share any necessary information with Easterseals Eastern Pennsylvania throughout the school year.
*I hereby authorize Easterseals Eastern Pennsylvania to release and/or share results and any information necessary information with FAMILY CENTERS OF ALLENTOWN throughout the school year.
*I agree to be contacted by an Easterseals Specialist, who will share the results with me and also give me activities and/or as needed connect me to community resources in line with my child’s individual needs. CLICK HERE TO SEE EASTERSEALS EASTERN PA'S HIPAA STATEMENT
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.
