Weeks Premature
(put "0" if not premature)

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.