Social Cognitive Learning Group Form

Emotional Learning Groups - Summer 2022
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

Janell Larson, LCSW

Amy Malone, LCSW

Jamie Wiora, LCSW

Please complete this pre-registration form if interested in a Summer 2022 Emotional Learning Group.
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 upcoming 2022/2023school 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 Choice (select one): *

Artistic expression and the Polyvagal Theory – Jamie Wiora, LCSW-Tuesday 2:30 Girls age 9-12 Teen DBT Group- Courtney Brown, LCSW & Jessica Amedeo, LCSW - Weds. 6pm age 14-17 Calm & Confident Teens – Jessica Amedeo, LCSW - Day/Time TBD age 14-16
Diagnosis, health conditions, medications, and/or special diets?
240 Character Max
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 & Other 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 emotional/social behavior at home, school and/or in the community: *
Briefly describe 3 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:
Questions or additional information to share?
Insurance: *

Blue Cross Blue Shield PPO -In Network Out of Network-submit claims as a courtesy Self Pay
Let's Stay Connected
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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Emotional Learning Groups - Summer 2022

Client Information

Primary Contact Information

Education & Other Information

Other Information

Let's Stay Connected