PEERS for Young Adults (18-40)
Program for the Education and Enrichment for Relational Skills
40 Dean St. Unit A
Tuesdays 4:30-6:00 PM Starting March 4th through April 22nd
Name of Young Adult
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age at the time PEERS begins
Name of Guardian (if participant is their own guardian, please leave blank)
First Name
Last Name
Best email to use for communications regarding this PEERS group
example@example.com
Best phone number to use for communications regarding this PEERS group
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DDS Eligibility
ASD
ASD/ID
Not DDS Eligible
Unsure
Social Coaches must be present at all of the sessions
A social coach can be a parent/guardian, adult sibling, relative, pca, or anyone that has a significant role in the young adults' life. We'd prefer it was the same person each week, but we understand that things come up. Please discuss any issues with a CAR staff
Social Coach
First Name
Last Name
Social Coach Email
example@example.com
Social Coach Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
The cost of this program is $200
Please let us know the best way to process payment
Please Select
Cash
Check
Paypal
Venmo
Payment due after you receive an email confirmation.
To receive a certificate of completion, you must attend 7 out of the 8 sessions. (If you know that you are unable to make one of the meetings due to a scheduling conflict, please wait until the next session).
I understand
I will have to wait until next session
Other
Can Community Autism Resources use your photograph for marketing purposes on our website, Facebook, Instagram, and flyers promoting PEERS?
Yes, I give CAR permission to use my photo
No, I do not give CAR permission to use my photo
Are there any dietary restrictions for young adult and/or social coach (we will be serving snacks and drinks)
Lastly, please choose a time that works for a 15 minute phone conversation to discuss the program and expectations. Both teen and social coach should present on this phone call.
What is the phone number to call for this meeting?
Please enter a valid phone number.
Format: (000) 000-0000.
If you have any questions or concerns please reach out to Sarah at SWalkden@community-autism-resources.com
Registration is limited. Payment wont be required until you recieve a confirmation email
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