Parent/Guardian Referral & Intake Form

Complete this form to request non-clinical mentoring and behavioral support services for a youth ages 5–17. Submission of this form does not guarantee acceptance of services. A member of Empower Youth Behavioral Services LLC will contact you to discuss availability and next steps.

Parent/Guardian Name *

Parent/Guardian Email *

Reason for Referral *

Youth Name *

Youth Age *

Phone Number *

Referral Source

Service Requested *

Mentoring
Behavioral Support
Community-Based Support

Insurance/Medicaid Plan *

Preferred Days & Times *

Best Method of Contact *

Phone
Text
Email

Consent to Be Contacted *

I give Empower Youth Behavioral Services LLC permission to contact me regarding this referral.