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)

For ASQ:SE-2™ English

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For ASQ-3™ English

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We look forward to your participation in our program.  Have fun completing this questionnaire with your child. Please call or email me at any time if you have any questions or would like to discuss any concerns about your child’s development.

CONSENT TO SHARE MY CHILD'S INFORMATION AND FOLLOW UP:

*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

*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 above statements, by completing the ASQ-3 and ASQ:SE-2 questionnaires.  

*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.