PARENT / GUARDIAN CONSENT FORM
Developmental and/or Social Emotional Screening ASQ-3 (Ages and Stages Questionnaire)
ASQ-SE2 (Ages and Stages Questionnaire – Social / Emotional)

____I DO GIVE PERMISSION to the staff of ____________________ (preschool, child care center or FCCH) to complete developmental and / or social emotional screenings for my child / children. This would be in the areas of communication, gross motor, fine motor, problem solving, and social / emotional development. I understand that the information will be submitted online through http://www.elcduval.org/developmental_screenings/

I understand that as part of Care coordination a Specialist from the Early Learning Coalition of Duval may contact me to discuss the results of the screenings and about necessary follow up services for my child / children from other agencies like: Speech and Hearing Center, Child Guidance, Early Steps, Child Find, Hope Haven, Children’s Home Society, Kids Hope Alliance, and Episcopal Children’s Services.

____I DO NOT GIVE PERMISSION to the staff of ____________________ (preschool, child care center or FCCH) to complete developmental and / or social emotional screenings for my child / children.

	CHILD’S FULL NAME	CHILD’S DATE OF BIRTH	
1			
2			
3			
4			

__________________________________________________________________________
         Parent / Guardian Name - Print                                                                      Contact Number                    

__________________________________________________________________________
         Parent Signature                                                                                                   Date

(Consents are valid for 1 year from date signed)

Please Fax to 904-394-1228