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

Daring Way Groups for Teens

Please complete this application form if you are interested in an upcoming session of our Daring Way Groups for Girls/Teens based on the research of Dr. Brené Brown. See our website for more information.

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 9/2018-2019 Fall *

We are interested in groups for *

Fall/Spring only

Summer group only

Both

New Client or current client *

Yes - new client

No - current or past client

Summer 2019 group choice: *

Middle School Girls

High School Girls 9th & 10th

High School Girls 11th & 12th

Other (future group) Other (future group)

Please check all times you are available. *

Tuesday 7pm

Wednesday 7pm

Thursday 7pm

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

Please place us on a your mailing list for updates

Please contact us regarding individual therapy

Email: *

School District and School Name *

Classroom placement *

General Education

Resource Room

Self Contained Classroom

Other Other

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

IEP

504 or other Plan

N/A

Please check current services received *

Resource/Academic support

Social Worker/Psychologist

Speech and Language

N/A

Please describe your child's personal strengths, areas of interest and extracurricular activities *

Please list classes or subjects your child/teen does best in at school: *

Please list classes or subjects your child/teen struggles with most at school: *

Describe any challenges your teen is currently struggling with including social, emotional, academic or other. *

Please describe your teen's social interactions with peers. *

Diagnosis, health conditions, medications, allergies, or special diets?

Questions? or other info to share?

0/255 characters

Parent/Guardian Information

Parent/Guardian Names *

Child primarily resides with *

Both parents

Mom

Dad

Other Other

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

Referred by

Insurance information

Name of insured

Insurance Carrier *

Date of Birth:

Group Number

ID number

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