PEERS® Adolescent Social Skills Group Interest Form
Please take the time to fill out this form. Upon receipt, families will be contacted.
PEERS for Adolescents is for those in middle and high school.
Email address *
Adolescent's Name *
Your answer
Adolescent's Date of Birth *
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Parents' Names *
Your answer
Phone Number *
Your answer
Address *
Your answer
What school does your child attend? What grade? *
Your answer
How did you learn about about our PEERS Program? *
Your answer
The PEERS Program for Adolescents is a parent-assisted intervention for adolescents in middle and high school that are having difficulties making or keeping friends. Is the adolescent in middle or high school, and would this program be of interest to his/her family? *
There is a parent component of the PEERS Program which requires one parent to attend on a consistent basis. Another parent is welcome to attend, but for continuity, parents may not trade-off attending. Would at least one parent be available to consistently attend the program with the adolescent? *
There are separate parent and adolescent sessions that meet at the same time for 90-minutes each week over a 14-week period. Parents are taught how to help their adolescent make friends by acting as social coaches outside of the group. Would parents agree to complete all homework assignments? *
Does the adolescent want to have friends and learn new strategies? Would s/he be motivated to learn how to make new friends and attend the class? 1= extremely resistant, 5= Is open to being helped and wants desperately to improve. *
What are the adolescent's favorite activities or special interests? (e.g., Star Wars, board games, video games, manga) *
Your answer
What road block(s) does the adolescent have making friends? Please check off all options that apply. *
Required
Does the adolescent have any type of psychological or medical diagnosis? Please check off all options that apply. *
Required
Is the adolescent taking any prescription medications right now? If yes, please list medications. *
Your answer
How severely affected is the adolescent's communication? This will help us understand his/her language and conversational abilities. 1= Uses echolalia, brief sentences or single words, needs frequent adult support, very limited verbal expressive abilities, 5=Mainstreamed in advanced academic classes, socially awkward, trouble making/keeping friends *
What educational classroom setting is the adolescent currently placed in? *
Academically, is the adolescent taking any classes below grade level? *
Academically, my child has a(n) : *
Required
Is the adolescent currently receiving any services at or outside of school? *
If yes, please indicate which services (i.e., speech-language, social skills, behavioral services, occupational therapy, counseling therapy, etc.)
Your answer
Does the adolescent have any aggressive behavioral difficulties at home or school? Please check off all options that apply. *
Required
Does the adolescent have a group of friends at school? *
Does the adolescent have get-togethers with peers or have friends come over? *
Here are a few topics covered in the PEERS Program class. Which of the following skills does the adolescent require assistance with? Please check off all options that apply. *
Required
Any other questions or comments? *
Your answer
A copy of your responses will be emailed to the address you provided.
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