Social Cognitive Learning Group Form

Summer 2023 - Social Skills & Group Therapy
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

Jamie Wiora, LCSW

- When forming our groups, we consider the social understanding, social skills 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.
Social-Emotional Groups are typically offered by semester: Fall, Winter/Spring, and Summer.
Client Information
Client Name*

FirstMiddleLast
Date of Birth:*
Gender*
Grade for current 2022/2023 school year:*
Options: Elementary through High School only. If no option applies, select Other
New or Current Client:*

Yes - new clientNo - current or past client
Diagnosis, health conditions, medications, and/or special diets?
240 Character Max
We are interested in groups for:*

FallWinter/SpringSummer
Group Choice:

Please choose 1 of the group options listed below:
For Elementary & Middle School Groups (select one):*

Calm, Confident & Crafty 2nd-4th grade; Wed 6:15 pm June 7th-July 19th Courtney BrownSocial Theatre Group -3rd-5th grade- Sat 9am Shawn AmadorSocial Theatre Group- Junior High- Sat 11 am Shawn AmadorChill Out-Learning to navigate the Nervous System-Jr High- Mondays 11 am, June 12-24, Janell LarsonN/AOther
For Teens:*

Resilient & Regulated Tweens: An Introduction to DBT - Ages 11-13 - Jessica Amedeo, LCSW Ages 11-13; Maximum 4 participants Tuesdays 5-6pm, 8 weeks starting June 13thResilient & Regulated Tweens: An Introduction to DBT - Ages 11-13- May 10th Start DateDrama Therapy for Anxiety- Sat 12 noon, starting June 3rd, Shawn AmadorChill Out-Learning to navigate the Nervous System-High School Mondays 12:15, June 12-24 Janell LarsonN/A
Primary Contact Information
Primary Contact Name:*
Primary Cellular Phone #:*

Area CodePhone Number
Primary Contact's Email *
example@example.com
Client resides with:*

MotherFatherBoth parentsOther
Client Address:*

Street Address

Apartment/Unit Number

CityState

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

General EducationResource RoomSelf Contained ClassroomHomeschoolTherapeutic SchoolNone ApplyOther
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 client academically struggles with most:
Please describe personal strengths, area(s) of interest, and extracurricular activities:*
Please provide your concerns regarding emotional, social, behavioral functioning at home, school, work and/or in the community:*
Please describe relationships and interactions with family, peers, adults and others at school, in activities, community, work and/or other settings:*
Briefly describe 3 social and/or emotional goals and/or how you hope this group will benefit participant? *
1)
2)
3)
Other Information
Please tell us how you found out about our office or heard about our social/emotional groups:*
Name of Referral Source:
Questions or additional information to share?
Insurance:*

Blue Cross Blue Shield PPO-In NetworkOther Insurance submit claims as a courtesySelf-Pay
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Summer 2023 - Social Skills & Group Therapy

Client Information

Group Choice:

Primary Contact Information

Education/Employment & Social Information

Other Information

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