ASQ-SE-2 Consent Form

Consent Form

The first 5 years of life are very important. Social-emotional development within the first few years of life prepares your child to be confident, trusting, curious, and able to develop positive relationships with others. Your child’s positive social-emotional development forms a foundation for learning throughout life.

Please read the text below and mark the desired space to indicate whether you will participate in the screening/monitoring program.

O I have read the information provided about the Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2™), and I wish to have my child participate in the screening/monitoring program. I will fill out questionnaires about my child’s social-emotional development and will promptly return the completed questionnaires.

I do not wish to participate in the screening/monitoring program. I have read O the provided information about the Ages & Stages Questionnaires®: Social- Emotional, Second Edition (ASQ:SE-2™), and understand the purpose of this program.

___________________________________________________________________________________ Parent or guardian’s signature

_______________________________________________ Date

Child’s Name:_______________________________________________________________________

Child’s date of birth:_________________________________________________________________

If child was born 3 or more weeks prematurely, # of weeks premature:______________________

Child’s primary physician:_____________________________________________________________

Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2™), Squires, Bricker & Twombly. © 2015 Paul H. Brookes Publishing Co., Inc. All rights reserved. Ages & Stages Questionnaires® is a registered trademark and ASQ:SE-2™ is a trademark of Paul H. Brookes Publishing Co., Inc. www.agesandstages.com | 1-800-638-3775 |