Brookes ASQ | ASQ:SE2 - ASQ-3 English

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Early Learning Coalition of Lake County
1300 Citizens Blvd. Suite 206
Leesburg, Florida 34748
www.elclc.org

Nicole Adkins, Child Development Coordinator

For more information about the Early Learning Coalition or about the ASQ Screener, please contact us at (352) 435-0566, Monday - Thursday, 8:00am - 5:00pm.

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ:SE-2™ English

Screening Date

I am screening my child today (2024-12-27) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

For ASQ-3™ English

Screening Date I am screening my child today (2024-12-27) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

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.

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