Page 1 of 2
Program for the Education & Enrichment of Relational Skills (PEERS) Initial Questionnaire
Please complete this initial questionnaire when booking your call so I have a better understanding of your teen/young adult prior to our call. Thank you. - Vivian
Email Address
*
Date Today
*
PEERS Program Start Date:
*
PEERS Program Start Date:
Teens Group 1 - Teen Session: Tuesdays from 5 August 2025 @ 4.30-6pm / Parent Session: Mondays from 4 August 2025 @ 7-8.00pm
Teens Group 2 - Teen Session: Wednesdays from 6 August 2025 @ 5.00-6.30pm / Parent Session: Wednesdays from 6 August 2025 @ 7-8.00pm
Young Adults - Young Adult Session: Tuesdays from 5 August 2025 2025 @ 6.30-8pm / Parent/Social Coach Session: 4 August 2025 @ 5-6.00pm
Teen/YA Name
*
Gender
*
Gender
A
Male
B
Female
C
Other
Date of Birth
*
Age
*
School and Grade/Uni/Work
*
Where did you hear about us?
*
Family Information
*
Family Information
A
Bio parents
B
Adoptive Parents
C
Foster
D
Group Home
E
Two Parent
F
Single Parent
Who will attend social coach sessions:
*
Who will attend social coach sessions:
A
Bio-mum
B
Bio-dad
C
Step-mom
D
Step-dad
E
Other
Parent/Social Coach Name:
*
Address
*
Mobile
*
Diagnosis (if any):
Meds (if any):
If teen, are you
*
If teen, are you
In High School
IQ above 70
Experiencing social problems?
Young Person and parent fluent in English
Parent/Guardian willing to participate
Other
Type of School Setting (if applicable):
Major mental illness (schizophrenic, bipolar). Specify
*
Physical disability of relevance. Specify
*
Behavioural Problems (check all that apply)
*
Behavioural Problems (check all that apply)
Inappropriate classroom behavior (if at school)
Trouble with academic work
Violence/aggression
Fire setting
Stealing
Severe property destruction
Argumentative /tantrums/disobeying
Parent afraid of child
Previously hospitalized for behaviour
Other
Social Problems (check all that apply)
*
Social Problems (check all that apply)
No get-togethers
No friends at school/community
Socially isolated/withdrawn
Social anxiety
Trouble making friends
Trouble keeping friends
Inappropriate peer group
Aggressive or mean to peers
Teased/bullied
Rejected by peers
Socially awkward
Trouble understanding social cues
None of the above
Other
What else would you like me to know about your teen/YA?
Submit
