West Coast Centre for Learning - PEERS Initial Questionnaire - Youth Gr. 7-12 Spring (Online) Class April 7

PEERS for Teens Spring Online (4:00pm) Class

Cost: $1495

3/12 upcoming

Tuesday 4:00 PM - 5:30 PM

April 7, 2026, April 14, 2026, April 21, 2026, April 28, 2026, May 5, 2026, May 12, 2026, May 19, 2026, May 26, 2026, June 2, 2026, June 9, 2026, June 16, 2026, June 23, 2026

0 spots left

Register *

Participant

First name *

Last name *

Gender *

Date of birth *

Minimum age 11 years 9 months.

Grade *

Name of School Attending *

Parent/Guardian

Already have an account?

Connect

You will receive a confirmation by email.

Relationship

First name *

Last name *

Email *

Mobile *

Address *

City *

Country *

State/Province *

Zip/Postal code *

Does your child live with you full time or part time?

Other parent (Optional)

Relationship

First name *

Last name *

Email *

Mobile *

Address

City

Country

State/Province

Zip/Postal code

Does your child live with you full time or part time? *

What is your preferred method of communication? *

Phone Text Email Zoom

Do you have Internet access with a stable connection in your home? *

Yes No

PEERS is a parent-assisted intervention for teens in middle and high school that are having difficulties making or keeping friends. Is your teen in middle or high school *

Yes No

Other (please comment)

Background Questions

The following questions will help us to understand how your teen is coping socially. *

Difficulty conversing with other teens No friends at school Teased or bullied Never receives invitations for outside social gatherings i.e birthday parties/events Inappropriate friendships (younger/older teens) Self Isolating Aggression toward peers No social gatherings outside school

Other

Does your teen want to have friends and will they be motivated to make new friends and learn new strategies? *

Yes No Somewhat

What special interests or activities does your teen engage in?

School Information

The following questions refer to your teen's performance at school.

What type of classroom setting is your teen currently placed in? *

All day self contained Special Education classroom All day mainstreamed classroom Majority mainstream with some Special Education or therapeutic classes Majority Special Education with some general education classes Homeschool/Online School Situation

Other

Is your teen on a modified or adapted program? *

Yes, adapted Yes, modified No

Questions About Behaviour

Does your teen have any behaviour concerns that may limit/interfere with their participation in the program? *

Yes No

Please explain

Questions About Participation

The following questions refer to your family's ability to attend and participate.

There is a parent component of the PEERS Program which requires one parent to participate on a consistent basis. *

Another parent is welcome to attend, but for continuity, parents may not trade-off attending. Would at least one parent be available to consistently attend the program with the teen if and when required?

Yes No

There are separate parent sessions that meet over the program period. *

Parents are taught how to help their teens make friends by acting as social coaches outside of the group. Would parents agree to attend and complete all homework assignments?

Yes No

Will your teen be motivated to attend sessions on a regular basis? *

Yes No Somewhat

It's important not to institute change during the program period (i.e. changes to medication, residence, school, etc.). *

Will there be any big changes for your teen during the program period?

Yes No

The environment is very important to the successful participation & completion of the program. *

Please consider a quiet distraction free environment for your teen as it's very distracting for other participants to have other family members/activities going on in the background.

Can you provide this type of environment for your teen?

Yes No

How did you hear about West Coast Centre for Learning? *

Referred by Family or Friend Referred by a Professional ACT Community Training Internet Search Social Media Other

If by family, friend or professional, please list their name below. If other, please specify.

Would you like to receive our newsletter with helpful parenting tips, program information, and special offers. (You can unsubscribe at any time) *

Yes please! No thanks

I consent to having photographs and work samples of my child/ren through Zoom, to be used by West Coast Centre for Learning in promotional material. * *

Yes No

Will you be accessing funding to pay for the program? *

Yes, Autism Funding Yes, School Funding No, bill me privately

If school or other funding, please list below.

Please list any questions, comments or concerns that you may have, if any:

Electronic signature

Please sign your name inside the box

Thank-you for completing the PEERS for Teens pre-interview questions.

Upon submitting this form, you will receive a copy of your responses, and a confirmation email containing with a link to schedule your intake interview. During the interview, which will take approximately 30 minutes, you will have the opportunity to discuss your responses, ask questions, and clarify any details.

Thank you for choosing West Coast Centre for Learning, we look forward to connecting with you. If you require immediate assistance, please feel free to contact us: info@wccl.ca or (778) 839-5515

By submitting this form, you consent to West Coast Centre for Learning collecting and using your information to respond to your inquiry. For details on how your data is stored and protected, please review our Privacy Policy.