New Client Inquiry

Today's Date

MonthDay Year
Date
Client Name

First Name Last Name
Client Age:
Client Date of Birth:*

MonthDay Year
Date
School/District or Employer
Parent/Contact Name if different than client

First Name Last Name
Relationship to Client
Phone Number*

Area Code Phone Number
Insurance:

Blue Cross Blue Shield PPOOut of NetworkLyraSelf Pay - Not using insurance
Email*
example@example.com
Best Day and Time to Call:
Please share your concerns?

Anxiety/StressDepression/MoodSchool IssuesAttention DifficultiesBehavior challengesEmotional Regulation challengesSocial SkillsGrief/LossParenting skills and supportFamily Stress
Services you are seeking?

Individual TherapyGroup TherapyFamily/Parenting SupportSSP (Safe and Sound Protocol)
Request for a therapist, if available:

Shawn Amador, LCSWJessica Amedeo, LCSWCourtney Brown, LCSWColleen Hanson, LCSWJanell Larson, LCSWJamie Wiora, LCSW

Availability:

Due to Covid-19 please let us know the type of session you prefer?*

Prefer In-Office onlyPrefer Online onlyOpen to either
Please share how you found us:
Name of person who referred you to us:
Name of who referred you
Other information to Share:
Completed by: *

First Name Last Name
Should be Empty: