New Client Inquiry Form
Thank you for your interest in CORE Connection Counseling. We will confirm receipt of this form by email and will follow up with a phone call once we have an opening to discuss scheduling and answer any questions.
Today's Date
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Month
-
Day
Year
Date
Client Name
First Name
Last Name
Client Date of Birth:
*
-
Month
-
Day
Year
Date
Client Age:
Administrative Sex (gender at birth)
Please Select
Female
Male
Other
Choose not to disclose
Client Employer
School/District (if a student)
Grade Level
Please Select
Pre-school
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
HS-freshman
HS-sophomore
HS-junior
HS-senior
College
other
School year:
Current school year
Grade level for fall
Parent/Contact Name if different than client
First Name
Last Name
Relationship to Client
Phone Number
*
-
Area Code
Phone Number
Best Day and Time to Call:
Email
*
example@example.com
Please sign me up for the CORE Connection Newsletter (typically sent once a month).
*
Yes
No, thank you
Insurance:
Blue Cross Blue Shield PPO
Out of Network
Lyra
Self Pay - Not using insurance
Please share your concerns?
Anxiety/Stress
Depression/Mood
School Issues
Attention Difficulties
Behavior challenges
Emotional Regulation challenges
Social Skills
Grief/Loss
Parenting skills and support
Family Stress
Other
Services you are seeking?
Individual Therapy
Family/Parenting Support
Other
Request for a therapist, if available:
Shawn Amador, LCSW
Jessica Amedeo, LCSW
Courtney Brown, LCSW
Colleen Hanson, LCSW (waitlist currently closed)
Janell Larson, LCSW
Dana Sutton, LSW
Jackie Weber, LCSW
Jamie Wiora, LCSW
If requested therapist does not have current availability are you open to working with another one of our therapists:
Yes
No, I prefer to wait for the requested therapist.
Do you prefer telehealth appointments or in-office?
*
Prefer In-Office only
Prefer Online only
Open to either
What is the best way to contact you?
Prefer email
Prefer phone call
Prefer texting
Any way works
Availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning 9-12 pm
Early Afternoon
1 pm-3 pm
Late Afternoon
3 pm-5pm
Evening 5 pm-8 pm
Please share how you found us:
Website
Internet Search
Physician Referral
School Referral
Friend
Other Provider
Psychology Today
Other
Name of person who referred you to us:
Name of who referred you
Other information to Share:
Completed by:
*
First Name
Last Name
Submit
Should be Empty: