PEERS® Social Skills Class Intake

PEERS® Social Skills Class Intake
Introduction
Please read the following class description/requirements carefully!

PEERS is a parent-assisted intervention for adolescents in middle and high school who are having difficulty making friends.

There are separate parent and teen sessions that meet weekly for 90 minutes each week over a 14-week period. The group focuses on skills like:
- Having conversations
- Entering and exiting conversations
- Electronic forms of communication
- Making phone calls to friends
- Choosing appropriate friends
- Handling teasing/bullying/rejection
- Handling arguments and disagreements
- Having appropriate get togethers
- Being a good sport
Parents are taught how to help their teens make and keep friends by acting as social coaches outside of the group. During the teen session, teens are presented with a lesson and then practice whateer skill they just learned while participaing in socializaaionactivities or playing board games, card games or outdoor sports. Homework assigments are also given each week to make sure teens are practicing the skills they are learning.

Each family will need to attend one parent meeting and one teen meeting per week. Meetings are held for 1.5 hours on the following days:
- In-person teen sessions - Monday Evenings
- Online teen sessions - Tuesday evenings
- Online parent sessions - Sunday evenings
All online sessions are run on Google Meet. Many school computers and accounts do not allow access to meetings with outside Google accounts. Your teen will need access to a computer that will allow this.

For consistency, the same parent must be able to attend at least 11 of the 14 sessions to maintain enrollment.

It's important to know that we do not force anyone to participate in these groups. This means your teen must be willing to attend the groups voluntarily.

PEERS® Social Skills Classes are NOT a friendship matching program. Participants are asked to not socially engage with other participants outside of the group during the course of the 14 week session.
Is this something you are still interested in and willing to commit to?*

YesNo
Does this sound like something your teen would be interested in attending?*

YesNo

Thank you for your interest
Unfortunately you answered "no" to one or more of the previous questions and we don't believe this program would be a good fit for you and/or your teen.

If you would like referrals to other programs that may better meet your needs, please email us at contact@gameonyouth.com. You may also continue to talk to your teen about the benefits of our program to see if they'll become more interested. If you email us their questions we will respond within 48 business hours!

Thank you!

Intake Screener
Completion of this form does not guarantee a placement in a social skills class. The information will be reviewed and you will be contacted with a decision regarding whether or not your teen meets certain criteria to be successful in the program.

You will be contacted via email within one week regarding whether or not our program can help your teen be successful. Please add the domain @gameonyouth.com to your safe senders list.

If your initial intake form indicates that this program could benefit your child, we will reach out to schedule a 1-hour virtual visit with you and your teen to get more information, answer any questions you may have, and review program expectations. You will be asked to fill out additional rating forms as well as submit your payment in full. You will not be placed in a class until we have recieved your forms, payment and have conducted your virtual visit.

Note: This form does not need to be completed in one sitting. You may click the "save" button at the bottom of each page to save your progress or have a link emailed to you to complete it later.

Parent/Guardian Information
Person filling out this form*

First NameLast Name
Relationship to participant*
Additional Parent/Guardian involved (if applicable)

First NameLast Name
Relationship to participant
As previously mentioned, the PEERS program involves a parent training portion which requires at least one parent or guardian to attend on a consistent basis. A second parent or guardian is always welcome to join in the parent trainings.
Who will be the main parent/guardian attending?*
Parent/Guardian Email Address*
Parent/Guardian Phone Number*

Participant Information
Participant's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Must be 11-17 to participate
Preferred Pronouns*
Ex: he/him, she/her, they/them
Current Grade*
Must be in grades 6-12 to participate
What school do they attend?*
Does your teen have any siblings?*

YesNo
Please list the ages of siblings*

Mental Health / Medical Background
Does your teen have any significant behavioral issues at HOME?*

YesNo
Has your teen's teacher reported significant behavioral issues at SCHOOL?*

YesNo
Please explain the behavioral challenges which exist*
Has your teen ever received any type of psychological or medical diagnosis?*

YesNo
Please list any and all diagnoses below*
Does your teen currently take any medications*

YesNo
Please list all medications and dosages below*

Program Selection
Which program format(s) are you interested in?*

VirtualIn PersonEither virtual or in person
Which sessions are you interested in? (check all that apply)*

Fall 2024 (Sept-Dec) - VIRTUAL ONLYWinter 2025 (Jan-May)Spring/Summer 2025 (Jun-Sept)
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PEERS® Social Skills Class Intake

Introduction

Thank you for your interest

Intake Screener

Parent/Guardian Information

Participant Information

Educational / Social Background

Mental Health / Medical Background

Program Selection