Registration

Your interest in the Peers Teens and Parents Training Programs are highly appreciated. This program is offered by Vybrant Potentials, a neurodivergent consultant agency, and will be solely conducted on zoom for 16 weeks. The Program for the Education and Enrichment of Relational Skills (PEERS®), is an evidence-based social skill program facilitated towards individuals within the neurodivergent community.

For each grouping, we make compatible groups of participants ranging from 8 to 10. We are strategic in our lesson planning and group individuals with similar interests together.

Spaces are limited, so if interested please complete the following Intake Forms and you will be guaranteed a space in our Program(s).

Teen Section

To be completed by the teen enrolling in the Peers Teen Program

Name

Date of Birth

Why are you interested in the Peers Teen Program?

What are your hobbies?

Do you have any other interests other than hobbies?

What is your favorite movie?

How would you define the word friend?

Do you have any friends?

Whenever you hang out with your friends what are some of your interests?

Do you participate in any group activities like clubs, sports, or teams?

Social Coach Section (Parent's Training)

To be completed by the social coach. A teen's social coach should be someone who can support the teen through the Peers Teen Program, such as a parent, who helps to reinforce learned skills outside of the sessions. Each teen should have 1 coach who attends every PTP session.

Social Coach Name

Phone Number

Email address

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

How would you prefer to make payments? Total payment for the Peers Teen Program is $880. For the Parents Training and the Peers Teen Program combined, the total cost is $1,760. PLEASE NOTE: Due to limited space availability, no refunds will be provided after the 1st month of the program.

$60 Weekly

Peers Teen Program ONLY

$240 a month

Peers Teen Program ONLY

Three installments of $320. The first payment is due on the first day of the program, the second is due 1 month after the program begins, and the third is due 2 months after the program begins

Peers Teen Program ONLY

$110 Weekly

Parents Training and Peers Teen Program COMBINED

$440 a month

Parents Training and Peers Teen Program COMBINED

Three installments of $586.66. The first payment is due on the first day of the program, the second is due 1 month after the program begins, and the third is due 2 months after the program begins

Parents Training and Peers Teen Program COMBINED

What short term goals would you like your teen to achieve in the Peers Teen Program?

What long term goals would you like your teen to achieve in the Peers Teen Program?

What are some of your teen's hobbies?

Do they have any interests outside of hobbies?

Please describe the length of your teen's attention span.

What school does your teen attend?

Describe the learning environment of your teen's schooling. (Public / Private School, Home School / Hospital Homebound)

Does your teen engage in maladaptive behaviors we should be aware of? If yes, please explain.

On a scale of 1 to 5, please rate how well your teen responds to quesitons.

1 is needs repeated prompting, 5 is responds independently.

On a scale of 1 to 5, please rate how well your teen follows directions.

1 is needs repeated prompting, 5 is follows directions independently.

On a scale of 1 to 5, please rate how interested your teen is in making friends.

1 is NOT interested, 5 is very interested

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