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MoCo PEERS® Application Form
Initial Screening Form for MoCo PEERS®
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* Indicates required question
Email
*
Your email
NAME AND DATE OF BIRTH OF TEEN / YOUNG ADULT: PLEASE INCLUDE DATE OF BIRTH.
*
Your answer
NAME OF PARENT(S) OR CAREGIVER(S)
*
Your answer
PARENT EMAIL
*
Your answer
PARENT PHONE
*
Your answer
TEEN / YOUNG ADULT EMAIL
Your answer
TEEN / YOUNG ADULT PHONE
Your answer
FAMILY ADDRESS
*
Your answer
OTHER/ADDITIONAL ADDRESS (if applicable, please include name on address)
Your answer
PARENTS PARTNERSHIP STATUS
*
Partnered
Single
Married
Divorced
Required
DESCRIBE YOUR RELATIONSHIP BETWEEN YOU AND YOUR TEEN OR YOUNG ADULT
*
Your answer
TEEN'S / YOUNG ADULT'S MENTAL HEALTH DIAGNOSES, LEARNING DISABILITIES, AND MEDICAL DIAGNOSES
*
Your answer
NAMES OF PROVIDERS WHO GAVE DIAGNOSES (Please include providers who gave mental health diagnoses, medical diagnoses, and learning disabilities)
Your answer
DISABILITY IN INTELLECTUAL FUNCTIONING
*
Yes
No
Other:
VERBAL/SPEECH DELAYS
*
YES
No
Other:
DESCRIBE YOUR TEEN / YOUNG ADULT'S VERBAL ABILITIES
*
Your answer
EDUCATIONAL STATUS AND/OR EMPLOYMENT STATUS OF TEEN / YOUNG ADULT
*
Attending High School
Attending College
Employed
Not in school or employed
Other:
PLEASE STATE NAME OF SCHOOL, GRADE IN SCHOOL, AND/ OR EMPLOYMENT LOCATION IF APPLICABLE
*
Your answer
PLEASE MARK ANY BEHAVIORAL CHALLENGES THAT ARE SIGNIFICANT FOR YOUR TEEN OR YOUNG ADULT
*
trouble with home/school work
violence/aggression
inappropriate classroom or work setting behavior
fire setting
stealing
severe property destruction
argumentative
parent afraid of teen or young adult
previously hospitalized for behavior
Other
Other:
Required
PLEASE MARK SOCIAL CHALLENGES
*
no get-togethers
no friends at school/community
socially isolated
social anxiety
trouble making friends
trouble keeping friends,
inappropriate peer group
aggressive or mean to peers
teased/bullied
rejected by peers
socially awkward
trouble understanding social cues
Required
PLEASE DISCUSS YOUR TEEN OR YOUNG ADULT'S STRENGTHS AND INTERESTS
*
Your answer
PLEASE DISCUSS PARENTS' STRENGTHS AND INTERESTS
*
Your answer
WHAT DO YOU (PARENT) HOPE TO GAIN FROM THE PEERS® PROGRAM?
*
Your answer
WHAT DOES YOUR TEEN OR YOUNG ADULT HOPE TO GAIN FROM THE PEERS® PROGRAM?
*
Your answer
PLEASE DESCRIBE YOUR TEEN'S / YOUNG ADULT'S CURRENT KNOWLEDGE OF AND WILLINGNESS TO PARTICIPATE IN THE MoCo PEERS® PROGRAM.
*
Your answer
PLEASE DESCRIBE ANY CONCERNS YOUR TEEN / YOUNG ADULT MAY HAVE ABOUT THE PEERS® PROGRAM.
*
Your answer
PLEASE PROVIDE ANY FURTHER INFORMATION YOU WOULD LIKE US TO UNDERSTAND
Your answer
PLEASE CHECK ALL POSSIBLE DATES YOU AND YOUR TEEN OR YOUNG ADULT COULD BE AVAILABLE FOR A VIRTUAL INTAKE MEETING
*
Winter 2023, Saturday morning times
Winter 2023, Saturday afternoon times
Winter 2023, Friday morning times
Winter 2023, Friday afternoon times
Other:
Required
A copy of your responses will be emailed to the address you provided.
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