Brookes ASQ | ASQ:SE2 - ASQ-3 English

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WELCOME EASTERSEALS EASTERN PA FAMILY! YOU ARE ABOUT TO ACCESS OUR ASQ ONLINE SCREENING PROGRAM!

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ:SE-2™ English

Screening Date

List others assisting with completion of the questionnaire

For ASQ-3™ English

Screening Date

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 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

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