WELCOME! YOU ARE ABOUT TO ACCESS THE AUTISM DIAGNOSTIC CLINIC'S ASQ ONLINE SCREENING AND MONITORING PROGRAM WITH EASTERSEALS EASTERN PA!

This questionnaire includes questions about your child’s ability to calm down, follow directions, demonstrate feelings, and interact with others.  The SE-2 is offered every 6 months until your child is 3 years old, and then again at 4 years old and 5 years old. 

We look forward to your participation in our program.  Have fun completing this questionnaire with your child.Select a time your child is happy, alert, and ready to play.  Make it a game and you’ll both have fun!  If completing this questionnaire brings up any questions or concerns, please don’t hesitate to contact me.  

Regards, 

Christina Reilley

MtFFC Program Coordinator                                                     

Easterseals Eastern PA                                         

www.easterseals.com/esep 

[email protected] 

P: 610-289-0114 x232  



(put "0" if not premature)



 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 the AUTISM DIAGNOSTIC CLINIC 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 the AUTISM DIAGNOSTIC CLINIC 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.

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