PEERS® Virtual Adolescent Social Skills Group Interest Form

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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 *

Adolescent's Name *

Adolescent's Preferred Pronouns
*

Adolescent's Date of Birth

YYYY

Caregivers' Names *

Caregiver Preferred Pronouns

Phone Number *

Address *

What school does your child attend? *

In what grade is your child? *

What educational classroom setting is the adolescent currently placed in? *

All day in self-contained special education classroom

All day in general education classes (mainstream)

Majority general education with 1-2 special education or therapeutic classes (i.e. resource room)

Majority special education with 1-2 general education electives (i.e. PE)

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? *

Yes

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? *

Yes

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? *

Yes

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) *

What road block(s) does the adolescent have making friends? Please check off all options that apply. *

No friends at school

Difficulty making new friends

No get-togethers (i.e. "Hangouts")

Teased or bullied

Aggressive with his/her peers

Does not get invited to other's houses or birthday parties/events

Other kids do not like the teen (possibly a bad reputation)

Difficulty conversing with other teems

Classroom behavior problems

Self-isolating

Inappropriate friendships (younger/older people)

Impulsivity in their interactions with peers

Other:

Required

Does the adolescent have any type of psychological or medical diagnosis? Please check off all options that apply. *

ASD: Autism

ASD: Asperger Syndrome

ASD: PDD-NOS

ADD/ADHD

Anxiety

Obsessive-compulsive disorder (OCD)

Oppositional defiant disorder (ODD)

Mood disorder/Depression

Bipolar disorder

Schizophrenia

Visual or hearing impairment

Severe articulation or speech issues

No diagnosis

Other:

Required

Is the adolescent taking any prescription medications right now? If yes, please list medications. *

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 *

Academically, is the adolescent taking any classes below grade level? *

Yes, some classes s/he takes are below grade level

No, all classes s/he takes are at or above grade level

Academically, my child has a(n) *

IEP

504 Plan

Behavior Intervention Plan/Behavior contract

None of the above

Other:

Required

Is the adolescent currently receiving any services at or outside of school? *

Yes

If yes, please indicate which services (i.e., speech-language, social skills, behavioral services, occupational therapy, counseling therapy, etc.)

Does the adolescent have any aggressive behavioral difficulties at home or school? Please check off all options that apply. *

Inability to function without 1-on-1 aide

Violent, aggressive behaviors toward adults or teens

Teen not able to function within a group setting

Teen does not respond when people set limits

None apply

Other (enter in notes below)

Other:

Required

Does the adolescent have a group of friends at school? *

Yes

Does the adolescent have get-togethers with peers or have friends come over? *

Yes

Other:

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. *

Having two-way balanced conversations

Entering and exiting conversations (i.e. approaching a group of peers who are talking in a circle

Electronic forms of communication (i.e. appropriately using Facebook, email, texting, phone class, voicemails)

Choosing appropriate friends

Handling teasing, bullying, rumors, gossip, etc.

Handling arguments and disagreements with friends/siblings

Having appropriate get-togethers with friends

Being a good host to friends and guests

Being a good sport

Other:

Required

How did you learn about about our PEERS Program? *

Any other questions or comments? *

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