Parent Support – Client Intake & Referral
(For Your Child)
Because every child deserves support, understanding, and a plan.
 

Why this form is important:

When your child is struggling, the right help—at the right time—makes all the difference.
Our Client Intake & Referral Form helps our team:

• Understand your child’s current challenges (emotional, behavioral, school-related).

• Identify safety concerns and immediate needs.

• Match your family with the best next step: in-house support (mentoring, groups, art sessions, family workshops) or a professional referral (counselor/therapist, school resources, psychiatry, community partners).

• Reduce delays—so your child receives faster, more focused care.

Completing the form takes about 8–10 minutes and helps us serve your child with care, clarity, and urgency.

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What to expect after you submit:

1. Confirmation: You’ll receive an on-screen confirmation (and email if provided).

2. Review: Our team reviews your responses within 1–2 business days.

3. Next Step: We contact you with a recommended plan—Empower Purpose services and/or referrals.

4. Follow-Up: If a referral is made, we’ll offer to assist with the connection and schedule a follow-up check-in.

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What you’ll need:

• Basic information about your child (name, age, school, language preferences)

• A brief summary of your main concerns

• Any previous services (counseling/therapy/medication), if applicable

• Best contact information for you

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Your privacy matters:

• Your information is kept confidential and used only to provide support and referrals.

• We do not share your information without your consent, except when required for safety.

• Empower Purpose is not a medical provider and not a crisis line. If your child is in immediate danger, please use the emergency resources below.

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