PEERS 14-Week Social Skills Group Intake Form
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Email *
Child's Full Name *
Child's Date of Birth (MM/DD/YYYY) *
Child's Gender *
Child's Grade Level *
Child's School Name *
Parent/Guardian 1 Full Name *
Parent/Guardian 2 Full Name (if applicable) *
Primary Phone Number *
Secondary Phone Number (if applicable) *
Email Address *
What is the best time of day for a follow-up phone call regarding your child's progress? *
Which days of the week work best for scheduling follow-up calls? *
What is your child's primary social challenge that you hope the PEERS program will address? *
How does your child typically respond when social interactions don't go as expected? *
In group settings, your child most often: *
What motivates your child most effectively in social learning situations? *
How does your child best process and retain new social skills information? *
What is your primary goal for your child's participation in this program? *
How would you describe your child's current peer relationships? *
A copy of your responses will be emailed to the address you provided.
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