New Client Online Inquiry

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:

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:
Name of person who referred you to us:
Name of who referred you
Other information to Share:
Completed by: *

First Name Last Name
Should be Empty: