PEERS® Social Groups - West Vancouver Application Form: Please enable JavaScript in your browser to complete this form.Client Name (Child/Service recipient): *FirstLastDate of Birth (YYYY/MM/DD) *e.g. 2014/03/12 for March 12, 2014Sex: *MaleFemaleXPronouns:Name of Guardian (individual completing this form): *FirstLastWhat is your relationship to the client? *For example: mother, father, stepparent, grandparent, social worker, self-referral.Language:If other than English, what is your dominant language? Phone Number: *Preferred phone number(s); Identify home or mobile with H or M after the number. Address *Street Number, City, Province, Postal CodeEmail: *Please provide the names of all legal guardians (if client is under 19): *Second Guardian InformationRelationship, Language, Address, Phone; If different than first guardian.Secondary Email (if guardians are not together, please provide second guardian contact)Is there another email that you would like correspondence sent to as well (e.g., another parent)? Are all legal guardians consenting to and/or participating in this treatment? *YesNoWe are required to have consent from all legal guardians in order to provide services. If this is a concern, please let us know as soon as possible.If separated or divorced, has sole guardianship has been established? (You will need to submit the supporting paperwork when contacted by our intake team) *Yes, I have legal documentation that I am the sole guardianNo, I have no documentation that I am the sole guardianNo, sole guardianship has not been establishedNot applicable (parents are together/married)If sole guardianship has not been established then both parents are required to provide signed consent for services (eg. parents are separated or divorced). Please note that ABLE Clinic is not able to provide psychological services if guardianship is in active dispute and all parties do not consent to services.Does your teen (service recipient) have any type of psychological or medical diagnosis? *Please put "N/A" or equivalent, if there is no relevant history for this item or the next.Does your teen have any siblings? If so, what are their names and ages? *Do you or your teen have any food allergies? If so, please indicate allergy: *Does your teen have any behavior difficulties in the home or school setting? *Name of School and Grade (if in school) *Name of contact from school:Email of school contact: *If we were to observe your child at school, please describe what we would see during structured (learning) and unstructured (recess/lunch/breaks) times? *Does your child have an Individualized Education Plan?Academically, is your child taking any classes below grade level?Academically, is your child on an adapted or modified program?What other services is your teen currently receiving? *Skills: Is motivated to make new friends? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Is able to engage in a two-way conversation using on topic statements and questions? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Is able to start and enter conversations appropriately? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Is able to exit conversations appropriately? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Is able to use electronic information appropriately? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Is able to choose and make appropriate friends with similar interests? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Is able to be successful in a group setting? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Is able to be a good sport? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Has get-togethers at home, friend's house, or in the community? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Is able to resolve conflict and manage arguments appropriately? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Has mentioned they have been teased or bullied? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlySkills: Is able to understand the feelings and perspectives of others? *Does not engage in behaviourEngages in behaviour rarelyEngages in behaviour some of the timeEngages in behaviour most of the timeEngages in behaviour consistentlyOther comments and anything you would like me to know about your teen? *PhoneSubmit Share this:TwitterFacebookLike this:Like Loading...
