New Client Inquiry

New Client Inquiry Form

Thank you for reaching out, we look forward to working with you.
Getting Started

1) Complete this online form and we will match you with a therapist and reach out by phone, email or text to introduce the therapist and schedule your intake appointment.

or

2) If you have questions about our practice, therapists, or would like to schedule an information call, please complete the form and then use the calendar at the bottom to schedule a convenient time. We will call you then!

Thank You!
Today's Date

MonthDayYear
Date
Client Name*

First NameLast Name
Client Date of Birth:*

MonthDayYear
Date
Client Age:
Administrative Sex (gender at birth)
Client Employer
School year:

Current school yearGrade level for fall
Grade Level
School/District (if a student)
Parent/Contact Name if different than client

First NameLast Name
Relationship to Client
Phone Number*

Area CodePhone Number
Intake appointment preference: (please mark all that apply)

DaytimeEveningsTelehealthIn-person
Best way for us to contact you to schedule an intake appointment:
Text, Email, or Call with best day and time.
Email*
example@example.com
Please sign me up for the CORE Connection Newsletter (typically sent once a month). (Current clients will be notified of important practice updates by email or through the portal.)

YesNo, thank you
Insurance:

Blue Cross PPOLyraSelf Pay - Not using insuranceOut of Network
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, LCSW (Saturday's only)Jessica Amedeo, LCSW (7 yo -Adult)Courtney Brown, LCSW (8 yo- Adult)Colleen Hanson, LCSW (waitlist currently closed)Jaclyn Schramm, LCSW (5 yo-Young Adult))Janell Larson, LCSW (8 yo-Young Adult)Dana Sutton, LCSW (4 yo- Young Adult)Jackie Weber, LCSW (10 yo-Young Adult)Jamie Wiora, LCSW (8 yo- Adult)
If requested therapist does not have current availability are you open to working with another one of our therapists:

YesNo, I prefer to wait for the requested therapist.
Do you prefer telehealth appointments or in-office?*

Prefer In-Office onlyPrefer Online onlyOpen to either
What is the best way to contact you to schedule an intake appointment ?

Prefer emailPrefer phone callPrefer textingOther

Therapy appointment time availability:

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning 9, 10, 11 am
Early Afternoon Noon, 1, 2, or 3 pm
Late Afternoon 4, 5 or 6 pm
Evening 7 or 8 pm

Please share any other information about schedule and availability.
Please share how you found us:
Name of person who referred you to us:
Name of who referred you
Schedule an information call:
Other Client information to Share:
Completed by: *

First NameLast Name
Should be Empty:

New Client Inquiry Form