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PEERS Initial Questionnaire - Young Adults (Online) Spring 2024

PEERS Initial Questionnaire - Young Adults (Online) Spring 2024

This confidential and secure questionnaire will provide key information that will help us determine if PEERS may be a good fit for you. You will need approximately 15 minutes to complete the questionnaire. Please give as much information as possible. Upon receipt of your response, we will contact you to determine your suitability for the program.

Date * / MM / DD YYYY
Name * First Last
Gender *

Gender Male Female Other Other
Birthdate * / MM / DD YYYY
Email *
Phone (home) * - ### - ### ####
Cellular Phone - ### - ### ####
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
What is your preferred method of communication? *

What is your preferred method of communication? Phone Text Email Zoom
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
Can you manage computer use and a Zoom platform on your own? *

Can you manage computer use and a Zoom platform on your own? Yes No
Background Questions:

The following questions will help us to understand how you are coping socially.
Do you want to have friends and will will you be motivated to make new friends and learn new strategies? *

Do you want to have friends and will will you be motivated to make new friends and learn new strategies? Yes No Somewhat
What special interests or activities do you engage in? *
Medical Background
Do you have a psychological or medical diagnosis. Please list any: *
Are you taking any medication? If so, please list and explain. *
Questions about Behaviour:
Do you have any behaviour concerns that may limit/interfere with your 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 social coach component of the PEERS Program which requires a social coach to participate on a consistent basis. Would you have a social coach available to consistently attend the program with you if and when required? *

There is a social coach component of the PEERS Program which requires a social coach to participate on a consistent basis. Would you have a social coach available to consistently attend the program with you if and when required? Yes No
There are separate social coach sessions that meet over the program period. Social coaches are taught how to help you make friends by acting as social coaches outside of the group. Would your social coach agree to attend and complete all homework assignments?* *

There are separate social coach sessions that meet over the program period. Social coaches are taught how to help you make friends by acting as social coaches outside of the group. Would your social coach agree to attend and complete all homework assignments?* Yes No
Will you be motivated to attend sessions on a regular basis? *

Will you 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 you 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 you during the program period? Yes No
The environment is very important to the successful participation & completion of the program. Please consider a quiet distraction free environment as it's very distracting for other participants to have other family members/activities going on in the background. Can you provide this type of environment? *

The environment is very important to the successful participation & completion of the program. Please consider a quiet distraction free environment as it's very distracting for other participants to have other family members/activities going on in the background. Can you provide this type of environment? 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.

PEERS Initial Questionnaire - Young Adults (Online) Spring 2024

PEERS Initial Questionnaire - Young Adults (Online) Spring 2024

Background Questions:

Medical Background

Questions about Behaviour:

Questions About Participation:

Thank-you for completing the PEERS pre interview questions.