Social Cognitive Learning Group Form

Winter/Spring 2021 Groups
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

Jackie Weber, LCSW

Jamie Wiora, LCSW

Client Information
Today's Date

Month Day Year
Date
Client Name *

First Middle Last
Gender *
Date of Birth: *
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 or Middle School) Mindful Movement 3rd- 5th grade Big Life Journal Group Let's Create Young Adult Social Conversation Group Parent's Have Feelings Too Social Theatre- Full for Fall, please complete waitlist form on website.
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
Client Address: *

Street Address

Apartment/Unit Number

City State

Postal / Zip Code
School Information

Please complete for Child, Teen, Young Adult Groups if applicable.
School Name and/or District:
Does client have an IEP or 504 Plan?
Grade for 2020/2021school year:
Options: Elementary through High School only. If no option applies, select Other
School Placement:

General Education Resource Room Self Contained Classroom Homeschool Therapeutic School
Other Information
Please tell us how you found out about our office or heard about our groups: *
Name of Referral Source:
Health Insurance Carrier
Questions or additional information to share?
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Yes, sign us up for the CORE Connection News email list to receive updates on new groups and other practice information. (We promise not to spam you) *

Yes No, thanks
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example@example.com
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Winter/Spring 2021 Groups

Client Information

Primary Contact Information

School Information

Other Information

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