New Client Inquiry

New Client Inquiry Form

Completion of this form will place you on our waitlist which is now estimated to be 3-6 months as of July 1st, 2023. We will reach out when we have availability to schedule at the times you have indicated. Thank you for reaching out to us and we hope to connect with you as soon as possible.
Today's Date

MonthDayYear
Date
Client Name

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

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

First NameLast Name
Relationship to Client
Phone Number*

Area CodePhone 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).*

YesNo, thank you
Insurance:

Blue Cross Blue Shield PPOOut of NetworkLyraSelf Pay - Not using insurance
Please share your concerns?

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

Individual TherapyFamily/Parenting SupportOther
Request for a therapist, if available:

Shawn Amador, LCSWJessica Amedeo, LCSWCourtney Brown, LCSWColleen Hanson, LCSW (waitlist currently closed)Janell 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 NameLast Name
Should be Empty:

New Client Inquiry Form