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-3™ English

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

AUTHORIZATION FOR SCREENING SERVICES 

I acknowledge that I have the legal authority to grant permission to have my child screened by the Lifesteps’ Child Check Team using Brookes Publishing Ages & Stages Questionnaires (ASQ).

I understand and agree to the following:

·    Screening gathers information on my child’s thinking, talking, moving, hearing, etc.

·    Screening results are predicated upon my truthful completion of the questionnaire

·    Any other release of my child’s information shall require completion of Lifesteps Consent for Release of Information form

·    Lifesteps Child Check Team may provide screening results written and/or verbal and if applicable through the child care/preschool facility

·    Further evaluation may be provided at no cost to me by the Base Service Unit (BSU) or Intermediate Unit (IU)

·    If my child is screened as part of a child care/preschool facility, I agree to sign Lifesteps Consent for Release of Information form permitting Lifesteps to share results

·    My child’s records/information will only be released as permitted by applicable law and as set forth in Lifesteps HIPAA Notice of Privacy Practices 

I have read the provided information about the Ages & Stages questionnaires, and I wish to have my child participate in the online screening program. I will fill out the questionnaire about my child's development and promptly submit the completed questionnaire through this Family Access online questionnaire completion system. 

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.