New Client Inquiry

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 Stress
Services you are seeking?

Individual TherapyGroup TherapyFamily/Parenting SupportSSP (Safe and Sound Protocol)
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: