PEERS® for Teens Intake Form

PEERS® Program

Teen Participant Intake Form
Thank you for your interest in the PEERS® Program, offered by Autism Connections. PEERS®, or the Program for the Education and Enrichment of Relational Skills, is an evidence-based social skills program for individuals with autism and related social challenges. Autism Connections provides this program in two cohorts: PEERS® for Teens (ages 13-16) and PEERS® for Adults (ages 18+ Please read over the program description before completing this survey, available here.

For each cohort, we make cohesive groups of participants so that we can plan the pacing of lessons and group individuals with similar interests. Please complete this Teen Participant Intake Form, and we will offer you a spot in our seasonal cohorts as spots are available.

Note: Completion of the Teen Participant Intake Form does not guarantee a spot in the next PEERS® for Teens cohort offered by Autism Connections.
Social Coach Section

To be completed by the social coach. A teen's social coach should be someone who can support the teen through the PEERS® Program, such as a parent, who helps to reinforced learned skills outside of the sessions. Each teen should have 1 social coach who attends every PEERS® session.
Social Coach Name*
Zip Code*
Phone Number*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you prefer to pay for PEERS® for Teens?*

1 installment of $500, due on the first day of the program3 installments of $250 due on the first day of the program, $125 due 1 month after the program begins, and $125 due 2 months after the program begins
What are your short term goals with your teen's involvement in PEERS®?*
What are your long term goals with your teen's involvement in PEERS®?*
What are some of your teen's hobbies?*
What are some of your teen's interests besides hobbies?*
Please describe your teen's length of sustained attention?*
What school does your teen attend?*
Describe your teen's current learning environment at school. (Is your teen fully included in the public school classroom, or do they learn in a resource room?)*
Does your teen have behaviors we need to be aware of? (e.g. big feelings, disruption, aggression)*
On a scale of 1 to 5, please rate how well your teen responds to questions.*
(1 is needs repeated prompting, 5 is responds independently)
On a scale of 1 to 5, please rate how well your teen follows directions. *
(1 is needs repeated prompting, 5 is follows directions independently)
On a scale of 1 to 5, please rate how interested your teen is in making friends.*
(1 is NOT interested, 5 is very interested)
Teen Section

To be completed by the teen enrolling in the PEERS® Program.
Name*
Date of Birth*

MonthDayYear
Why are you interested in the PEERS® program?*
What are your hobbies?*
What are your interests besides hobbies?*
What is your favorite TV show?*
What is your favorite movie?*
What is a friend?*
Do you have friends? If so, how many?*
Do you ever hang out with friends? If so, what do you do together?*
Do you participate in any group activities like clubs, sports, or teams?*
Should be Empty:

PEERS® Program

Social Coach Section

Teen Section