Today's Date
-
Month
-
Day
Year
Date
Client Name
First Name
Last Name
Client Age:
Client Date of Birth:
-
Month
-
Day
Year
Date
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 PPO
Out of Network
Lyra
Not using insurance
Email
example@example.com
Best Day and Time to Call:
Please share your concerns?
Anxiety
Depression
School Issues
Attention Difficulties
Behavior challenges at home
Parenting skills and support
Social Skills
Family Stress
Grief/Loss
Services you are seeking?
Individual Therapy
Group Therapy
Family/Parenting Support
SSP (Safe and Sound Protocol)
Request for a therapist, if available:
Shawn Amador, LCSW
Jessica Amedeo, LCSW
Courtney Brown, LCSW
Amy Malone, LCSW
Jamie Wiora, LCSW
Jackie Weber, LCSW
Availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning 9-1 pm
Afternoon
2-5 pm
Evening
5-8pm
Due to Covid-19 please let us know the type of session you prefer?
Prefer In-Office only
Prefer Online only
Open to either
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
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