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 C
Lisle, IL 60532
630-524-4000
 
www.coreconnectioncc.com
www.colleenhansontherapy.com

Fall Social Theatre 2019

Please complete this application form if you are interested in an upcoming session for our groups. See our website for more information and specifics about groups being offered.
 
Participants in our 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
 
We will review the information submitted, request any additional information needed and schedule an intake appointment prior to final group placement.  The intake provides an opportunity for us to meet with you and your child prior to the start of group and to determine if the tenative group placement is a good fit for your child. We consider the social cognitive and emotional functioning level to place children who are matched well and working at the similar skill levels, in addition to age and grade level.
 
This process can be challenging and at times and it is possible we may not have a group available to best meet your child's needs. If we do not have a group available at this time, please indicate if you would like to be on our mailing/wait list for future groups.
 
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

We are interested in groups for *
Fall 2019 Groups: Days/Time TBD *
New Client or current client *
If a group opening is not currently available for my child/teen
Does your child/teen have an IEP or 504 Plan *
Classroom placement *
 
Please check current services received *
What are three social or emotional goals you have for your child/teen this year and/or for group sessions?
 Briefly describe
1.
2.
3.

Parent/Guardian Information

Child primarily resides with *
 
Primary contact *
 
Please indicate how you found us *
 

Insurance information

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