West Coast Centre for Learning - PEERS Initial Questionnaire - Youth Gr. 7-12 (Online) Winter 2025 - Jan 7

PEERS for Teens WINTER (Online) Class

Cost: $1495

No upcoming class

Tuesday 4:30 PM - 6:00 PM

January 7, 2025, January 14, 2025, January 21, 2025, January 28, 2025, February 4, 2025, February 11, 2025, February 18, 2025, February 25, 2025, March 4, 2025, March 11, 2025, April 1, 2025, April 8, 2025

Parent/Guardian

You will receive a confirmation by email.

Relationship

First name *

Last name *

Email *

Mobile *

Address *

City *

State/Province *

Zip/Postal code *

What is your preferred method of communication? *

Phone Text Email Zoom

Name of School Attending *

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 child 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 child'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. 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

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

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

Were you referred to our services? *

Yes No

If yes, who referred you?

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

Electronic signature

Please sign your name inside the box

Draw Type

×

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

A member of our team will be in contact with you shortly to schedule an intake interview. Upon submitting this form, you will receive a copy of your responses. You will have opportunity to discuss, clarify and ask any questions at the time of your interview, which will require you to schedule approximately 30 minutes of your time.

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