PEERS

The PEERS (Program for the Education and Enrichment of Relational Skills) program is an evidence-based social skills program that teaches middle and high school students how to make and keep friends. Topics on building friendships are taught and participants practice these skills with peers.

Some skills taught include:

• Using appropriate conversation skills
• Choosing appropriate friends
• Handling rejection, teasing and bullying
• Finding common interests

Group-based ABA Services Inquiry Form

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Child's First Name *

Child's Last Name *

Parent's First Name *

Parent's Last Name *

Email Address *

Phone Number *

Preferred Response *

• Email
• Phone call

Address *

Address Line 1

City

State / Province / Region

Postal Code

Does your child have a diagnosis of Autism? *

• Yes
• No

Are you registered with the Ontario Autism Program (OAP)? *

• Yes
• No

OAP Number

How old is your child? *

To better understand your child’s needs and recommend services that are best suited for your child, please answer the following questions:

1. How does your child communicate? *

• Does not speak (e.g., cries, points, or pulls)
• Does not speak but uses an alternative communication method (e.g., picture exchange, communication device)
• Speaks in 1-2 word phrases
• Speaks in full sentences, but may need support with having a conversation
• Speaks fluently and can speak about events from the past or future

Please select one.

2. Does your child engage in challenging behaviors that could require 1:1 support? *

• Elopement (i.e., runs away from you without informing you)
• Aggression (e.g., hits others, bites others)
• Property destructions (e.g., throws items, rips/ tears items)
• Self-injurious behaviours (e.g., hits self, bites self)
• None of the above

Please select all that apply.

3. What is your child’s current school placement? *

• Regular classroom with no additional supports
• Regular classroom with some supports (e.g., IEP, consultative services)
• Regular classroom with resource or withdrawal assistance (i.e., instruction from a special education teacher for parts of the school day)
• Specialized small group class placement (e.g., MID classroom, DD classroom)

Please select one.

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