Today's Date
-
Month
-
Day
Year
Date
Client Name
First Name
Last Name
Client Age:
Client Date of Birth:
*
-
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
Insurance:
Blue Cross Blue Shield PPO
Out of Network
Lyra
Self Pay - 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
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
Janell Larson, LCSW
Amy Malone, LCSW
Jamie Wiora, LCSW
Availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning 9-1 pm
Afternoon
2-5 pm
Evening
5-8pm
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: