Welcome to Easterseals Eastern PA’s ASQ:SE-2 questionnaire.



(put "0" if not premature)

For ASQ:SE-2™ English

For ASQ-3™ English

Consent

I have read the provided information about the MtFFC screenings.  I wish to have my child participate in the screening and monitoring program.  I agree to be contacted by an Easterseals specialist, who 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.  Information will only be shared with other agencies with your written 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.