PEERS Screening Record

Parent Name

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Parent Email*

example@example.com

Child's Name*

Age*

Date of Birth*

Date

Grade*

School*

Special Services:*

YesNo

Please describe services received in school:

1. What problems does your teen have making or keeping friends?*

2. Does your teen have a group of friends at school?*

3. Does your teen have get-togethers with peers? Or have friends over?*

4. How do those get-togethers usually go?*

5. What types of games or activities does your teen like?*

6. Does he/she play any sports?*

7. Is he or she in any extracurricular clubs or activities? *

8. Does your teen have any significant behavioral issues at home? *

9. Has your teen's teacher reported that your teen has any significant behavioral issues at school?*

10. Has your teen received any psychological or medical diagnosis? *

11. Is your teen on any medication? *

12. Who will be attending the program with your teen? *

13. Is this a two-parent or a single parent home? *

14. Does your teen have any siblings?*