Brookes ASQ | ASQ:SE2 - ASQ-3 English

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

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ-3™ English

Screening Date

List others assisting with completion of the questionnaire

For ASQ:SE-2™ 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 hereby authorize the AUTISM DIAGNOSTIC CENTER 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.