Peers Play Services Inquiry Form
Thank you for your inquiry into social groups and consultation services. By filling out this inquiry form, you are sharing information with us confidentially to determine whether our social groups may be a good fit for your child. Filling out this form IS NOT a commitment for services on your behalf or ours.

Once the form is received, please allow 2 weeks for us contact you. Our group sizes are currently very limited due to COVID concerns. In the event that we cannot fit your child into a group at this time, we will let you know and reach out if we have availability.
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Email *
Please confirm you email *
Parent / Guardian Names (First, Last) *
Phone Number *
Child's Name (First, Last) *
Child's Age *
Child's Date of Birth *
MM
/
DD
/
YYYY
Does your child have a relevant diagnosis?
What school does your child attend (if any)?
Grade current school year
Clear selection
Please select any supports you are interested in.  *
Required
What concerns bring you to seek services? *
Has your child received other interventions already? (i.e. ABA, OT, Speech, PT) Please provide a brief overview. *
What medical insurance provider do you use? Please note we do not bill insurance directly. *
How did you hear about PEERS Play? *
Required
If you are interested in a social group, what days / times is your child available for social groups?
Monday
Tuesday
Wednesday
Thursday
Friday
11:00-12:15 pm
1:45-3:00 pm
3:30-4:45 pm
4:15-5:30 pm
Anything else you would like us to know about your child?
Submit
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