Social Cognitive Learning Group Form

Fall 2024 - 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

Jaclyn, Schramm, LCSW

Dana Sutton, LCSW

Jackie Weber, LCSW

Jamie Wiora, LCSW

Thank you for your interest in our fall groups!!

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. An intake session is completed prior to finalzing placement in a group.

Please note, some groups are self pay only/educational groups (not eligible to bill insurance).
Therapeutic groups can be submitted to insurance for reimbursement.

We are in network with Blue Cross Blue Shield PPO, Blue Choice, and Blue Cross HPN.
Social-Emotional Groups are typically offered by semester: Fall, Winter/Spring, and Summer.
Client Information
Client Name*

FirstMiddleLast
Date of Birth:*
Gender*
Grade Level for 2024/2025 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
Group Choice:

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

Social Smarts Squad - Boys Group 4th -5th grade Thurs. 4-5pmConfident, Crafty Kids- Girls - 2nd-4th grade Wednesday 3:15Social Smarts Squad - Girls group 6th-7th grade Thurs. 6-7pmSocial Theatre Group-3rd-5th grade- Sat 9am Shawn AmadorSocial Theatre Group-6th-8th grade- Sat 10am Shawn AmadorN/A
High School:*

Peaceful Pathways for Teens - 13-18 (groups will be divided by age/grade level)N/A
For Young Adults:*

College & Career Transitions Group- 18 yo-mid 20's- Jackie Weber Thurs. Time TBDN/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
Client Employer (n/a if not employed)
School Name and District: (n/a if not in school)*
Does the client 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 client 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, Blue Choice, Blue Cross HPN-In NetworkOther 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
Should be Empty:

Fall 2024 - Social Skills & Group Therapy

Client Information

Group Choice:

Primary Contact Information

Education/Employment & Social Information

Other Information

Let's Stay Connected