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. BrenĂ© 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

We are interested in groups for *
New Client or current client *
Summer 2019 group choice: *
 
Please check all times you are available. *
If a group opening is not currently available for my child/teen
Classroom placement *
 
Does your child/teen have an IEP or 504 Plan *
Please check current services received *
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Parent/Guardian Information

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

Insurance information

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