CORE Connection Counseling

Colleen Hanson, LCSW

Shawn Amador, LCSW

Jessica Amedeo, LCSW

Amy Malone, LCSW

Jackie Weber, LCSW

Jamie Wiora, LCSW

6040 State Route 53, Suite B

Lisle, IL 60532

630-524-4000

www.coreconnectioncc.com

www.colleenhansontherapy.com

Group Waiting List

Please complete this form if you are interested in an upcoming session for our groups. We will send you our application for the next session of groups once it is available.

See our website for more information and specifics about groups being offered or add your name to our mailing list for updates.

Participants in our social groups should have average to above average verbal IQ and solid language skills because our programs incorporate the Social Thinking® materials and methodology, a language based learning approach. For more info, please visit www.socialthinking.com

Save & Return Account (optional)

New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish. The account you establish is only for this form.

Client Information

First Name *

Last Name *

Sex *

Birth Date *

Grade as of 9/2019-2020 Fall *

We are interested in groups for *

Fall or Winter/Spring group

Summer group only

Both

New Client or current client *

Yes - new client

No - current or past client

If a group opening is not currently available for my child/teen

Please add us to CORE Connection News email updates

Please contact us regarding individual therapy

Email address:

School District and School Name *

Does your child/teen have an IEP or 504 Plan *

IEP

504 or other Plan

N/A

Please mark the group or groups that you are interested in for your child/teen/parent. *

Little Social Explorers (age 3-4)

Social CBT Group (offered grades 1st thru 8th)

Social Theatre Group (offered grades 3rd-High School)

Emotional Regulation Group (offered grades 3rd-8th)

Daring Way Groups for Teens (Middle &High School girls)

Daring Way Groups for Parents

Question? or additional information to share?

Parent/Guardian Information

Parent/Guardian Names *

Cell Phone Mom

Cell phone Dad

Primary contact *

Mom

Dad

Other Other

Primary Contact Email Address *

Street Address *

City *

State *

Zip Code *

Primary Contact Phone Number *

Home or Alternate Phone

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