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
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Month
-
Day
Year
Date
Client Name
First Name
Last Name
Client Age:
Client Date of Birth:
*
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Month
-
Day
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
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
Jamie Wiora, LCSW
Availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning 8-12 pm
Early Afternoon
12 pm-3 pm
Late Afternoon
3 pm-5pm
Evening 5 pm-8 pm
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
Submit
Should be Empty: