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Form 
Adult (18+) Intake & Assessment 

Empower Purpose – Adult (18+) Intake & Assessment Form

Confidential – For Internal Use OnlyAll information provided will remain private and used only for the purpose of determining appropriate support, resources, and referrals.

SECTION 1: PERSONAL INFORMATION

Birthday
Month
Day
Year
Gender
Male
Female
Non-binary
Prefer not to say
Other:

SECTION 2: BACKGROUND INFORMATION

3. Have you sought support or professional help before?
Yes
No
SECTION 3: MENTAL & EMOTIONAL WELL-BEING Please check any of the following you are currently experiencing:
4. Have you ever experienced suicidal thoughts?
Yes
No
Do you currently feel you are in danger of harming yourself or others?
Yes
No

SECTION 4: PHYSICAL & MEDICAL INFORMATION

1. Do you have any medical conditions we should be aware of?
Yes
No
2. Are you currently taking any medications?
Yes
NO
3. Do you use alcohol or recreational substances?
Yes
No

SECTION 5: FAMILY, RELATIONSHIPS & SUPPORT SYSTEM

1. Marital/Relationship Status:
Single
Married
Divorced
Widowed
In a relationship
2. Do you have children?
Yes
No
3. Who do you live with?
Alone
Family
Partner
Friends
Other:

SECTION 6: EMPLOYMENT & HOUSING

1. Employment Status:
Full-time
Part-time
Unemployed
Student
Retired
Other:
3. Are you facing challenges related to:

SECTION 7: GOALS & SUPPORT NEEDED

2. What type of support are you seeking? (Check all that apply)

SECTION 8 – Referral Information

How did you hear about Empower Purpose?
Friend/Family
Social Media
Website
Community Partner
Event
Other

SECTION 9 – Consent Agreement (Required)

Consent & Acknowledgment

“I understand that Empower Purpose provides non-clinical support, life groups, art sessions, and referrals. I acknowledge this is not a substitute for professional mental health treatment. Empower Purpose may refer me to licensed mental health specialists or community partners when needed. I certify the information provided is accurate.”

I agree to the above terms.
I agree
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Date
Month
Day
Year

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Empower Purpose

"In the midst of the chaos, wars, and illnesses affecting our world today, we believe it's a time for unity rather than criticism or judgment. It's a time to come together, share our stories, and offer support and comfort to one another. Let's spread love and hope. Together, we can make a difference and create a better tomorrow."

​

Brenda M Nova

Email: empowerpurpose.org@hotmail.com

Phone: (702) 518-7416

​

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