## What Is ASQ:SE-2™? The first 5 years of your child’s life are very important. Your child’s healthy social-emotional development forms a foundation for lifelong learning. ASQ:SE-2 is a set of questionnaires about behavior and social-emotional development in young children. There are nine questionnaires for different ages to screen children from 1 month to 6 years old. ASQ:SE has been used by parents for more than 15 years. It makes sure that children’s social-emotional development is on schedule. It helps you celebrate milestones while addressing any concerns as early as possible. ASQ:SE-2 can help identify your child’s social-emotional strengths and areas where your child may need support. As a parent or caregiver, you are the best source of information about your child. That’s why ASQ:SE-2 is designed for you to complete. You will only need 10–15 minutes. It’s that quick and easy. Here’s how ASQ:SE-2 works: - Answer each question by marking “often or always,” “sometimes,” or “rarely or never.” Answer based on what you know about your child. - Note if any behaviors concern you. - Remember that your answers help show your child’s strengths and areas where he or she may need support. - After you finish, your child’s provider will discuss the results with you. If your child’s social-emotional development is on target, then there is nothing more you need to do. If there are concerns, then the provider will help you with next steps. When children get support as early as possible for behavioral concerns, problem behaviors may be prevented from getting more difficult as children get older. You play an important role in your child’s learning and development. Completing ASQ:SE-2 questionnaires helps you make sure your child is off to a great start! To find out more, please talk to your health care or education professional, or visit www.agesandstages.com. --- ## Dear Parent/Caregiver: Welcome to our social-emotional screening and monitoring program! The first 5 years of your child’s 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. As part of this service, we provide the Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2™), to help you keep track of your child’s social-emotional development. ASQ:SE-2 asks questions about your child’s behaviors and social-emotional growth. If the questionnaire shows that your child is developing without concerns, we will share some activities that you can do at home to encourage your child’s social-emotional development. Then, we will give you a questionnaire every 6 months until your child is 3 years old, and then again at 4 and 5 years old. If completing this questionnaire brings up any questions or concerns, we can talk about information and resources that can help. Information will be shared with other professionals or agencies only with your written consent. We look forward to your participation in our program. Please call or e-mail me at any time if you have any questions or would like to discuss any concerns about your child’s development. Sincerely, *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. --- ## 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. O I do not wish to participate in the screening/monitoring program. I have read 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. --- ## Demographic Information Sheet Today's date: _____ Child's name (first/middle/last): _____ Child's date of birth (MM/DD/YYYY): _____ / _____ / _____ If child was born premature, # of weeks premature: _______________________ Child’s gender: Male O O Female Child's race/ethnicity: _____ Child's birth weight (pounds/ounces): _____ Parent/primary caregiver’s name (first/middle/last): _____________________________________ Relationship to child: _____ Street address: _____ City: _____ State/province: _____ ZIP/postal code: _____ Home telephone: _____ Work telephone: _____ Cell/other telephone: _____ *Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2™), Squires, Bricker & Twombly.* © 2015 Paul H. Brookes Publishing Co., Inc. All rights reserved. E-mail address: _____ Child's primary language: _____ Language(s) spoken in the home: _____ --- ## Directions for completing ASQ:SE-2: 1. Please read each question carefully and check the response that best describes your child’s behavior: - Often or always: My child performs this behavior often or always. - Sometimes: My child sometimes performs this behavior (not consistently). - Rarely or never: My child rarely performs this behavior or has never performed the behavior. 2. Concerns: Check the circle to the right of a question if the behavior is a concern. 3. Some questions have blank spaces for you to provide examples of your child’s behavior. Please be sure to explain your response(s). 4. The Overall section at the end of the questionnaire asks open-ended questions about your child’s behaviors. Answer questions by marking yes or no and provide an explanation for your responses. Please be sure to send back the questionnaire within 2 weeks. Please contact me if you have any questions or concerns. --- ## Tips for completing ASQ:SE-2: Caregivers who know the child well and spend more than 15–20 hours per week with the child should complete ASQ:SE-2. Answer based on what you know about your child’s behavior. Answer questions based on your child’s usual behavior, not behavior when your child is sick, very tired, or hungry.