ASQ Consent Form

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ASQ Consent Form

Please complete this form along with your ASQ Questionnaires and Early Childhood Experiences Form.

Student Name

Childs birthday

YYYY

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

I do not wish to participate in the screening/monitoring program. I have read the provided information about the Ages & Stages Questionnaires: Social-Emotional (ASQ-3 and ASQ: SE-2) and understand the purpose of this program.

I do wish to participate in the screening/monitoring program. I have read the provided information about the Ages & Stages Questionnaires: Social-Emotional (ASQ-3 and ASQ: SE-2) and understand the purpose of this program.

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Parents name

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