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PEERS Screening Form
Please fill out all areas prior to your screening
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* Indicates required question
Email
*
Your email
Today's Date
*
Your answer
Name of Teen or Young Adult
*
Your answer
Gender
*
Your answer
DOB
*
Your answer
Age
*
Your answer
Grade
*
Your answer
School
*
Your answer
Referred by:
Your answer
REGIONAL CENTER SERVICE COORDINATOR Name and EMAIL if a regional center client:
Your answer
Parent 1 Name:
*
Your answer
Will Parent 1 Participate (i.e. Social Coach)?
*
Yes
No
Other:
Parent 2 Name:
*
Your answer
Will Parent 2 Participate (i.e. Social Coach)?
Yes
No
Clear selection
Address
*
Your answer
City and ZIP Code
*
Your answer
Phone number
Your answer
Leave Voicemail?
Yes
No
Other:
Clear selection
Text OK?
*
Yes
No
Email
*
Your answer
Diagnosis:
*
Your answer
Medications:
Your answer
Allergies
Your answer
Inclusion Criteria
Teen is in 6-12th grade
Young Adult is 18 -35 years old
Social Difficulties
Teen and Parent fluent in English
Parent willing to Participate
Teen/YA willing to Participate and is socially motivated
Other:
Exclusion Criteria
Aggression
Mood/Psychotic Disorder
Physical Disability
Medical Condition
Currently in crisis or recent hx
Other:
Behavioral Problems (Check all that apply):
School
Homework
Argumentative/Tantrums/disobeying
Property Destruction
Stealing
Physically hurts parents
Parents afraid of child
Previous hospitalization
Violence/Aggression
Other:
Other:
Social Problems (Check all that apply):
No get togethers
Inappropriate Peer Group
No friends in school/community
Aggressive/Mean to Peers
Socially isolated
Bullying/Teasing
Other:
Other:
Are you interested in an IN-PERSON Group or a Virtual Group? Select all that apply. Please let us know your preference, and we will work to deliver the best model safely to meet your needs.
*
In-Person Redondo Beach
In-Person Long Beach
Virtual/ONLINE Group (client is a resident of California)
Required
Comments
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