Social Cognitive Learning Group Form

Group Interest Waitlist
Welcome to CORE Connection Counseling

6040 State Route 53, Suite C
Lisle, IL 60532
P: 630-524-4000 / F: 630-524-2311

www.coreconnectioncc.com

Shawn Amador, LCSW

Jessica Amedeo, LCSW

Courtney Brown, LCSW

Colleen Hanson, LCSW

Amy Malone, LCSW

Jamie Wiora, LCSW

Wait List for future groups:

Please complete this application form if you are interested in being contacted for our next available group sessions.
- When forming our social groups, we consider the social cognitive and emotional functioning level (in addition to chronological age and grade level) to place children/teens/young adults in groups that are matched well and working at similar skill levels.
- Our groups are generally small and range from 2 to 6 participants, depending on the group.
- If you are interested in starting with individual therapy, please also indicate this and we will follow up with you.
Social groups are typically offered on a school semester schedule, Fall, Winter/Spring,and Summer.

Other groups are offered at different times throughout the year.

We are offering both telehealth and in-person groups.
Client Information
Client Name *

First Middle Last
Date of Birth: *
Gender *
We are interested in groups for: *

Fall/Spring only Summer only Both
Grade for 2020/2021school year: *
Options: Elementary through High School only. If no option applies, select Other
New or Current Client: *

Yes - new client No - current or past client
Group Type: (please select all that you are interested in)

Social CBT (Elementary & Middle School) Social Theatre (3-5th, or Middle School) Social Theatre (High School) Social Theatre (Young Adult/College Age) BIG Life Journal Group (3rd-5th) Daring Way Groups SPACE-Supportive Parenting for Anxious Childhood Emotions
Diagnosis, health conditions, medications, and/or special diets?
240 Character Max
If a group opening is not currently available please: *

Contact us regarding individual therapy. Keep us on the waitlist.
Primary Contact Information
Primary Contact Name: *
Primary Cellular Phone #: *

Area Code Phone Number
Primary Contact's Email *
example@example.com
Child/Teen client primarily resides with: *

Mother Father Both parents
Client Address: *

Street Address

Apartment/Unit Number

City State

Postal / Zip Code
Education & Social Information
School Name and District:
Does your child/teen have an IEP or 504 Plan?
Classroom Placement:

General Education Resource Room Self Contained Classroom Homeschool Therapeutic School
Current Services Received (select all that apply):
Please list classes or subjects your child/teen/adult does best in academically:
Please list classes or subjects your child/teen/adult struggles with most academically:
Please describe their personal strengths, area(s) of interest, and extracurricular activities:
Please provide your concerns regarding their behavior at home, school and/or in the community:
Please describe their social interactions with peers at school, during extracurricular activities, in the neighborhood and/or other social settings:
Briefly describe 3 social and/or emotional goals you have for your child/teen during the current school year and/or group sessions:
1)
2)
3)
Other Information
Please tell us how you found out about our office or heard about our social groups: *
Name of Referral Source:
Health Insurance Carrier
Questions or additional information to share?
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Yes No, thanks
Email
example@example.com
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Group Interest Waitlist

Client Information

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