Peers Application

Identifying Information

How did you hear about this program (who referred you to this program)?

I am completing this application for:

Applicant First Name

Applicant Last Name

Applicant Gender

Male

Female

Birthdate

Age

Applicant Address

City

US States

Zip

Phone

Email Confirmation

Education Information

Current School (if applicable)

Please indicate your / applicant's current program or classes.

Past school history (if applicable)

Applicant Work Information (if applicable)

Name of last employer

Postion

Dates of last employment

Name of previous employer

Postion

Dates of previous employment

Name of previous employer

Postion

Dates of previous employment

Current Services and Interventions

Please list the services and interventions received. Include both school-based and / or community services (i.e., speech therapy, psychotherapy, group therapy, school based services, psychiatric services, etc.).

Service Provider/Health/Medical Information

Please list all CURRENT providers (e.g., therapist, psychiatrist, etc.)

Please list any medications taken regularly.

What is your/applicant's current/most recent diagnosis? Who made the diagnosis?

Please describe any significant health conditions.

Please list any allergies.

Please list any special diet/food restrictions.

Further Information About Applicant

What special interests and strengths do you/does applicant have?

What are your/applicant's current areas of need or challenge?

What has been done so far to try to meet your/applicant's needs?

How is the issue of diagnosis discussed in the family and with others?

Please describe any behavioral difficulties (e.g. verbal or physical aggression, self-injurious behaviors, etc.).

Please add anything else you think we need to know about you/applicant.

Parent/Guardian Information

First Name

Last Name

Relationship to Applicant

Address

City

US States

Zip

Phone

Alternate Phone

Alternate Email

Preferred method of contact

Second Parent/Guardian Information

First Name

Last Name

Relationship to Applicant

Address (if different from above)

City

US States

Zip

Phone

Alternate Phone

Alternate Email

Preferred method of contact

Are there siblings or other significant family members in the home? (provide name, gender, age, and relationship to applicant).

Signature

By checking the box, I hereby make an application for me/applicant to attend PEERSÂ®Chicago Social Skills Intervention Program. I/We have filled out all of the information to the best of my/our knowledge. I/We understand that this is an application and that I/my family member has not been accepted to the PEERSÂ®Chicago Social Skills Intervention Program at this time.

I confirm this application is complete and accurate.

Date

Please feel free to use additional space if needed. It would also be helpful to provide a copy of a past or current IEP, psychological evaluation or any other documents that you feel may be helpful.

Submit

Diane Gould Therapy

Peers Application

Contact Information