Date *
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MM
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DD
YYYY
Teen's Name *
First
Last
Gender *
Gender
Male
Female
Birthdate *
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MM
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DD
YYYY
Parent/Guardian Name *
First
Last
Email *
Phone (home) *
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Cellular Phone
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Address *
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
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Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
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Cuba
Cyprus
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Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Greece
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Guinea-Bissau
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Hong Kong
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India
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Iran
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Israel
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Japan
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Libya
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Madagascar
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Malaysia
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Mali
Malta
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Nigeria
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Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
What is your preferred method of communication? *
What is your preferred method of communication?
Phone
Text
Email
Zoom
Name of School Attending
Do you have Internet access with a stable connection in your home? *
Do you have Internet access with a stable connection in your home?
Yes
No
PEERS is a parent-assisted intervention for teens in middle and high school that are having difficulties making or keeping friends. Is your teen in middle or high school? *
PEERS is a parent-assisted intervention for teens in middle and high school that are having difficulties making or keeping friends. Is your teen in middle or high school?
Yes
No
Other (please comment)
Other (please comment)
Will you be using Autism Funding for payment? *
Will you be using Autism Funding for payment?
Yes
No
Background Questions:
The following questions will help us to understand how your child is coping socially.
When it comes to making friends, what is the biggest obstacles your teen encounters? *
When it comes to making friends, what is the biggest obstacles your teen encounters?
Difficulty conversing with other teens
No friends at school
Teased or bullied
Never receives invitations for outside social gatherings i.e birthday parties/events
Inappropriate friendships (younger/older teens)
Self Isolating
Agression toward peers
No social gatherings outside school
Other
Does the teen want to have friends and will they be motivated to make new friends and learn new strategies? *
Does the teen want to have friends and will they be motivated to make new friends and learn new strategies?
Yes
No
Somewhat
What special interests or activities does your teen engage in? *
Medical Background
Does your teen have a psychological or medical diagnosis. Please list any: *
Is your child taking any medication? If so, please list and explain. *
School Information:
The following questions refer to your child's performance at school.
What type of classroom setting is your teen currently placed in? *
What type of classroom setting is your teen currently placed in?
All day self contained Special Education classroom
All day mainstreamed classroom
Majority mainstream with some Special Education or therapeutic classes
Majority Special Education with some general education classes
Homeschool/Online School Situation
Other
Other
Is the teen on a modified or adapted program?
Is the teen on a modified or adapted program?
Yes, adapted
Yes, modified
No
Questions about Behaviour:
Does your teen have any behaviour concerns that may limit/interfere with their participation in the program. Please explain: *
Questions About Participation:
The following questions refer to your family's ability to attend and participate.
There is a parent component of the PEERS Program which requires one parent to participate 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 teen if and when required? *
There is a parent component of the PEERS Program which requires one parent to participate 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 teen if and when required?
Yes
No
There are separate parent sessions that meet over the program period. Parents are taught how to help their teens make friends by acting as social coaches outside of the group. Would parents agree to attend and complete all homework assignments?* *
There are separate parent sessions that meet over the program period. Parents are taught how to help their teens make friends by acting as social coaches outside of the group. Would parents agree to attend and complete all homework assignments?*
Yes
No
Will your teen be motivated to attend sessions on a regular basis? *
Will your teen be motivated to attend sessions on a regular basis?
Yes
No
Somewhat
It's important not to institute change during the program period (i.e. changes to medication, residence, school, etc.). Will there be any big changes for your teen during the program period? *
It's important not to institute change during the program period (i.e. changes to medication, residence, school, etc.). Will there be any big changes for your teen during the program period?
Yes
No
Please list any questions, comments or concerns that you may have, if any:
Thank-you for completing the PEERS pre interview questions.
We will be in contact with you shortly to schedule a consultation.
Upon submitting this form, you will receive a copy of your responses. You will have opportunity to discuss, clarify and ask any questions at the time of your consultation. The consultation will require you to schedule approximately 15 minutes of your time.