MoCo PEERS® Screening Form
Initial Screening Form for PEERS®
Email address *
NAME AND DATE OF BIRTH OF TEEN / YOUNG ADULT *
NAME OF PARENT(S) OR CAREGIVER(S) *
PARENT EMAIL *
PARENT PHONE *
TEEN / YOUNG ADULT EMAIL
TEEN / YOUNG ADULT PHONE
FAMILY ADDRESS *
OTHER/ADDITIONAL ADDRESS (if applicable, please include name on address)
PARENTS PARTNERSHIP STATUS *
Required
DESCRIBE YOUR RELATIONSHIP BETWEEN YOU AND YOUR TEEN OR YOUNG ADULT *
TEEN'S / YOUNG ADULT'S MENTAL HEALTH DIAGNOSES, LEARNING DISABILITIES, AND MEDICAL DIAGNOSES *
NAMES OF PROVIDERS WHO GAVE DIAGNOSES (Please include providers who gave mental health diagnoses, medical diagnoses, and learning disabilities)
DISABILITY IN INTELLECTUAL FUNCTIONING *
VERBAL/SPEECH DELAYS *
DESCRIBE YOUR TEEN / YOUNG ADULT'S VERBAL ABILITIES *
EDUCATIONAL STATUS AND/OR EMPLOYMENT STATUS OF TEEN / YOUNG ADULT *
PLEASE STATE NAME OF SCHOOL, GRADE IN SCHOOL, AND/ OR EMPLOYMENT LOCATION IF APPLICABLE
PLEASE MARK ANY BEHAVIORAL CHALLENGES THAT ARE SIGNIFICANT FOR YOUR TEEN OR YOUNG ADULT *
Required
PLEASE MARK SOCIAL CHALLENGES *
Required
PLEASE DISCUSS YOUR TEEN OR YOUNG ADULT'S STRENGTHS AND INTERESTS *
PLEASE DISCUSS PARENTS' STRENGTHS AND INTERESTS *
WHAT DO YOU (PARENT) HOPE TO GAIN FROM THE PEERS® PROGRAM? *
WHAT DOES YOUR TEEN OR YOUNG ADULT HOPE TO GAIN FROM THE PEERS® PROGRAM? *
PLEASE DESCRIBE YOUR TEEN'S / YOUNG ADULT'S CURRENT KNOWLEDGE OF AND WILLINGNESS TO PARTICIPATE IN THE MoCo PEERS® PROGRAM. *
PLEASE DESCRIBE ANY CONCERNS YOUR TEEN / YOUNG ADULT MAY HAVE ABOUT THE PEERS® PROGRAM. *
PLEASE PROVIDE ANY FURTHER INFORMATION YOU WOULD LIKE US TO UNDERSTAND
A copy of your responses will be emailed to the address you provided.
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