New Client Inquiry Form
Thank you for your interest in CORE Connection Counseling. We will confirm receipt of this form by email and will follow up with a phone call once we have an opening to discuss scheduling and answer any questions.
Today's Date
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Month
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Day
Year
Date
Client Name
First Name
Last Name
Client Age:
Client Date of Birth:
*
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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
Best Day and Time to Call:
Email
*
example@example.com
Please sign me up for the CORE Connection Newsletter (typically sent once a month).
*
Yes
No, thank you
Insurance:
Blue Cross Blue Shield PPO
Out of Network
Lyra
Self Pay - Not using insurance
Please share your concerns?
Anxiety/Stress
Depression/Mood
School Issues
Attention Difficulties
Behavior challenges
Emotional Regulation challenges
Social Skills
Grief/Loss
Parenting skills and support
Family Stress
Other
Services you are seeking?
Individual Therapy
Family/Parenting Support
Other
Request for a therapist, if available:
Shawn Amador, LCSW (out of network provider)
Jessica Amedeo, LCSW
Courtney Brown, LCSW
Colleen Hanson, LCSW (waitlist currently closed)
Janell Larson, LCSW
Dana Sutton, LSW
Jackie Weber, LCSW
Jamie Wiora, LCSW
Availability:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Morning 8-12 pm
Early Afternoon
12 pm-3 pm
Late Afternoon
3 pm-5pm
Evening 5 pm-8 pm
Do you prefer telehealth appointments or in-office?
*
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: