Participant Application Over 18
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Participant's Information
Name *
(First, Last)
Pronouns
Date of Birth *
(Month/Day/Year)
Gender *
Name of Current School *
(if Transitioning, name transition school too!)
Street Address *
(Including City, State, and Zip Code)
How did you hear about us? *
Parent/Guardian's Information
Name *
(First, Last)
Relationship to Participant *
(Examples: Mother, Father, Grandfather, Nanny, etc.)
Primary Phone Number *
(Including Area Code)
Email Address *
Would you like to include your parent/guardian in correspondences with PeerBuddies? *
Emergency Contact Information
Name of Emergency Contact *
(First, Last)
Relationship to Participant *
(Examples: Mother, Father, Grandfather, Nanny, etc.)
Primary Phone Number *
(Including Area Code)
Do you have any allergies? *
If "Yes", to what?
(Please List All)
Program Preference & Scheduling 
Please select the program that you are most interested in enrolling in. We will do our best to accommodate your request depending on program and buddy availability.

Based on your availability, we will be matching you up with a buddy who has the same
availability.  Please note that buddies meet weekly on the same day of the week,
at the same time, for 10 weeks.  Please list ALL the days and times you are available so we
can ensure we find a match!
Please select the program you are interested in enrolling in:
(Please select all programs you are interested in) 
 *
Required
What day(s) of the week are you available to meet with your buddy? *
(Select all that apply!)
Required
When are you available to meet with your buddy? *
(Select all that apply!)
Required
Background Information
Please provide details regarding your current behaviors and the level of support required.  This information will prepare our team to ensure the appropriate supports are in place.  
Please indicate your diagnosis or reason for referral. *
(Select all that apply!)
Required
If response to previous question was "None", please describe reason for referral.
Please indicate the name of your insurance company. *
Please describe your current level of verbal language. *
If response to previous question was "No Verbal Language", please indicate:
Please describe your current level of reading comprehension skills.
 *
What is your primary language? *
Are you bilingual? If yes, please list additional language(s).
 *
Please describe your concerns with regard to your social skills. *
(Examples: "Difficulty initiating conversations"; "Needs help taking others' perspectives", etc.)
Please describe your concerns with regard to your behaviors. *
(Examples: "Gets frustrated quickly"; "Can be aggressive", etc.)
Please indicate "triggers" to challenging behaviors. *
(Examples: "When asked to clean up"; "When he/she sees a car", etc.)
What behavioral strategies have been effective for you?   *
(Select all that apply!)
Required
What additional information would you like us to know about you?
Participant Questionnaire
Please answer all of the following questions as completely as possible. We will use this information to determine the best match for your Buddy. The more details you give us, the better we will be able to find an appropriate match!

What are your favorite things to do/places to go?  Please list your hobbies and interests. *
How would you describe your personality? *
(Please select all that apply!)
Required
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