What Is the Intake & Assessment Form?

The intake form is a short questionnaire that asks about:

• Basic personal information

• Your current concerns and challenges

• Your mental and emotional well-being

• Your family, living situation, and support system

• Your employment, housing, and other practical needs

• The type of support you are seeking

It is not a test and there are no right or wrong answers.
It’s simply a tool to help us understand how we can walk alongside you.

 

How the Form Helps You

Completing the form is important because it allows us to:

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1. Offer the Right Type of Support

When we know what you’re going through, we can better determine:

• Whether a Life Group (support group), art session, or one-on-one support is the best fit

• Whether you might benefit from life coaching, personal development, or family/relationship support

• What kind of encouragement, tools, and resources will help you right now

 

2. Connect You to the Right Resources

Sometimes additional support is needed beyond what we offer.
Your form helps us know if it may be helpful to refer you to trusted community partners, such as:

• Mental and behavioral health services

• Housing or employment support

• Other community organizations that can support your specific needs

The more we understand, the better we can guide you.

 

3. Keep You Safe and Supported

Some questions on the form ask about:

• Emotional struggles (anxiety, depression, stress, grief, etc.)

• Thoughts of self-harm or feeling unsafe

• Substance use or difficult situations at home

These questions are not meant to judge you.
They are there to help us notice any urgent needs and respond with care, compassion, and appropriate support.

 

How We Use Your Information

Your information is used to:

• Learn about your situation and goals

• Determine which program(s) or group(s) may serve you best

• Identify if referrals to professional or community services are needed

• Track your progress and make sure we stay aligned with your needs

We do not share your private information with others without your knowledge, except in rare situations where someone’s safety is at risk (for example, if there is immediate danger of harm).

 

Your Privacy Matters

We understand that some questions may feel personal.
Please know:

• Your responses are confidential and used only for support and referral purposes

• You are always welcome to ask questions about any part of the form

• You can share at your own pace, but the more information you provide, the better we can help

Our goal is to create a safe, judgment-free space where you feel seen, heard, and respected.

 

What Happens After You Submit the Form?

Once you complete and submit the intake form:

1. Our team reviews your responses
   We carefully look over your answers to understand your situation.

2. We determine the next best step
   This may include:

   • Inviting you to a Life Group (Parents, Couples, Young Adults, Teens, etc.)

   • Inviting you to an art session or other activity

   • Offering one-on-one support or life coaching

   • Providing referrals to mental health professionals or community partners if needed

3. We contact you
   We will follow up using the phone number or email you provided to share next steps and answer any questions.

 

How Long Does the Form Take?

On average, the intake form takes about 10–15 minutes to complete.

We encourage you to:

• Find a quiet moment, if possible

• Be honest with your answers

• Remember that this form is for you—to help us better support your journey

 

You Are Not Alone

Life can be overwhelming—stress, family struggles, emotional pain, financial pressure, or feeling lost or stuck.
By completing the intake form, you are taking an important step toward:

• Being heard

• Being supported

• Finding hope and direction

At Empower Purpose, we truly believe you have a purpose, and you don’t have to walk through your challenges alone.

 

Ready to Begin?

If you’re ready to take the next step, click below to complete the Adult (18+) Intake & Assessment Form.

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