Parent/guardian Name
First Name
Last Name
Student Name
*
First Name
Last Name
Student DOB
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Grade
School
What are your teen's strengths?
What does your teen appear to be most successful with?
What is your teen motivated by?
Please indicate any concerns you might have about your teen:
Please indicate any pertinent medical history of your teen
RELATIONSHIPS: Please place a checkmark next to items that apply to your teen.
Too few friends
Talks to friends about their problems
Is overly shy
Makes friends easily
Enough friends
Doesn't talk to friends about problems
Finds it very difficult to open up to others
Finds it hard to keep friends
Please check any daily living/job skills that you would like your teen to work on:
Laundry (wash, dry, fold)
Vacuuming/Mop/Sweep floors
Clean mirrors/windows
Cleaning dishes/kitchen
Take out trash
Cooking
Other
Please indicate specific social skills that you would like your teen to work on.
As a parent/guardian, please indicate which challenges you are having in your relationship with
Parent: ANYTHING ELSE YOU WANT US TO KNOW?
Teen: What are the main things your would like to discuss in groups?
Parent: How did you hear about PACE?
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