West Coast Centre for Learning - PEERS Initial Questionnaire - Young Adults Winter/Spring (Online) Class - Feb 19

PEERS for Young Adults Winter-Spring Online Class - CANCELLED

Cost: $1695

1/16 upcoming

Thursday 7:00 PM - 8:30 PM

February 19, 2026, February 26, 2026, March 5, 2026, March 12, 2026, March 19, 2026, March 26, 2026, April 2, 2026, April 9, 2026, April 16, 2026, April 23, 2026, April 30, 2026, May 7, 2026, May 14, 2026, May 21, 2026, May 28, 2026, June 4, 2026

$1,695

Register *

Apply a coupon or a promo code

Participant

You will receive your receipt by email.

First name *

Last name *

Email *

Mobile *

Gender *

Date of birth *

Address *

City *

Country *

State/Province *

Zip/Postal code *

Other phone (home or work)

Parent/Social Coach (Optional)

Relationship

First name *

Last name *

Email *

Mobile *

Address if different from above *

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

Can you manage computer use and a Zoom platform on your own? *

Yes No

Background Questions:

The following questions will help us to understand how you are coping socially.

Do you want to have friends and will will you be motivated to make new friends and learn new strategies? *

Yes No Somewhat

What special interests or activities do you engage in? *

Questions about Behaviour:

Do you have any behaviour concerns that may limit/interfere with your participation in the program? *

Yes No

If yes, please explain

Questions About Participation

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

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

Would you have a social coach available to consistently attend the program with you when required?

Yes No

There are separate social coach sessions that meet over the program period. Social coaches are taught how to help you make friends by acting as social coaches outside of the group. *

Would your social coach agree to attend and complete all homework assignments?*

Yes No

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

Yes No Somewhat

If somewhat, please explain

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 you 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 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?

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 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 myself 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 Young Adults pre-interview questions.

Upon submitting this form, you will receive a copy of your responses. We will reach out to you shortly to schedule an intake interview. 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.

Once you click "Continue", you will be redirected to our payment page. If you are accessing funding for payment, please follow the instructions below.

Autism/School/Other Funding:
If you will be utilizing funding, please select "Autism/School/Other Funding" on the payment page, confirm which method of funding you will be using, then click the "I Confirm" button.

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.