PEERS Program Sign-Up

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The PEERS program is designed for teens diagnosed with Autism Spectrum Disorder, Level One, who want to improve their social skills and ability to make and keep life-long friends. The age range for the PEERS program is 13-18.

Participant Name *

Parent or Caregiver Name(s) *

Scheduling Contact Name *

Email for Scheduling *

Phone for Scheduling *

What is your participating teen's Age? *

Other:

What school and grade does you teen attend? *

Your Teen's Gender *

On what grade level would you estimate your teen reads? *

9th - 12th Grade Reading Level or Higher

7th - 9th Grade Reading Level

4th - 6th Grade Reading Level

1st - 3rd Grade Reading Level

Other:

Would your teen be able to remain mostly seated in a group setting for 50-60 minutes? *

Yes

Maybe

Other:

Does your teen struggle with impulse control and/or hyperactivity in public? *

How much anxiety do you estimate your teen would experience about talking and interacting in this program? *

Low Anxiety

Overwhelming Anxiety, Shutdown, Lash out, or Flee

Which of the social skills below would be helpful for your teen? *

Texing Etiquette

Making Phone Calls

Hosting Get Togethers

Identifying Potential Friends

Dating and Romance

Assertiveness & Speaking Up

Goal Setting

Setting or Respecting Boundaries

Self-awareness of Values, Personality, etc.

Recognizing Cons, Dishonest People, and Boundary Violators

Resolving Conflict

Dealing with Teasing and Bullying

Starting and Ending Conversations

Joining in and Leaving Others' Conversations

Health, Hygiene, and Self-care

Other:

Required

What are you hoping to get out of the PEERS program? *

Comments or questions? *

Please check the boxes below to indicate that you understand the PEERS Program Policies. I understand... *

Classes are held weekly for 4 weeks.

Your payment of $125 covers all four classes.

Payment is required before starting the program.

Refunds are only available in certain circumstances.

In the event that a participant engages in disruptive behavior, facilitators respond in 3 graduated responses. 1st = Verbal Redirection; 2nd = Five Minute Break in the Hallway; 3rd = Caregivers are notified.

The PEERS program maintains the right to remove any individual from the class for disruptive or inappropriate behavior, or if it becomes clear the participant is not yet ready or appropriate for PEERS.

Parent / Caregiver participation is expected as part of the program.

The PEERS program is not a good fit for every teen. We do our best to accommodate individual needs, but some teens need other interventions. If we discover your teen is not a good fit, we'll let you know and offer a pro-rated refund.

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This form was created inside of Arkansas Families First, LLC.