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 social and emotional 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 2023/2024 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):*

Social Theatre- 3rd-5th grade Sat 9 am-Self Pay onlySocial Theatre- Jr. High Sat 10 am Self Pay only- CLOSED for FALLN/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 ShieldOther Insurance submit claims as a courtesySelf-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)

YesNo, thanks
Email
example@example.com
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Summer 2023 - Social Skills & Group Therapy

Client Information

Group Choice:

Primary Contact Information

Education/Employment & Social Information

Other Information

Let's Stay Connected