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Month
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Day
Year
Date
Client Name
First Name
Last Name
Client Age:
Client Date of Birth:
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Month
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Day
Year
Date
School/District or Employer
Parent/Contact Name if different than client
First Name
Last Name
Relationship to Client
Phone Number
*
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Area Code
Phone Number
Best Day and Time to Call:
Email
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example@example.com
Please sign me up for the CORE Connection Newsletter (typically sent once a month)
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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
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
Colleen Hanson, LCSW (waitlist currently closed)
Janell Larson, LCSW
Jamie Wiora, LCSW
Availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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:
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First Name
Last Name
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