PEERS for Adolescents Intake Form

PEERS® for Adolescents Interest Form

Interested Teen Information

First Name *

Interested Teen

Last Name *

Age *

Participant must be 13-17 years old.

Birthday

Gender

Email *

Phone 1 *

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Are you comfortable speaking in front of and working with a small group of like minded peers? *

Why are you interested in learning about social and relationship based skills? *

What do you hope to achieve by taking this course? *

Are you a United States citizen and a resident of Arizona

Parent/Social Coach Information

Social Coach Relationship to PEERS Applicant *

First Name *

Last Name *

Age *

Email Address *

Phone Number *

How did you hear about ALL's PEERS for Adolescents?

Check all that apply to interested teen

Inclusion Criteria *

Teen is in 7th-12th grade

Exhibits social challenges

Teen and parent/social coach fluent in English

Has a parent/social coach willing to participate

Teen willing to participate

None of the above

Check all that apply

Social Challenges *

Does not attend get togethers

No friends in school or community

Socially Isolated

Mean to peers

Victim of bullying/teasing

None of the above

Check all that apply

Behavior Problems *

Tantrums/Outbursts

Property destruction

Physically hurts people

Displays violence/aggression

Previous hospitalization for behavior

None of the above

Check all that apply

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