Get Started - Empowerment Program, Inc.

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Home
SERVICES
Get Started
Black Lives Matter
PRIDE
Our Stories
CONTACT
Donate

1600 York Street
Denver, CO 80206

Start your journey with Empowerment.
Hope starts here...Welcome!

If you are only interested in HIV testing and do not wish to sign up for the program, click HERE.

I want to get tested for HIV

Step 1

Watch the WELCOME Orientation Intake Video

Step 2

Fill out the Pre-Intake Form
or Call 720-425-6293

Step 3

An Intake Specialist will contact you in the next 24 hours, or as soon as possible

PRE-INTAKE FORM - Contact an Intake Specialist

* Indicates required field

Name *

First

Last

Date of Birth *

Month/Day/Year

Gender Identity *

cisgender - your gender matches your assigned birth sex

What Gender Pronouns Do You Prefer? *

Race *

African American / Black American Indian or Alaska Native Asian Caucasian / White Native Hawaiian or Other Pacific Islander Other

Ethnicity *

Phone Number *

If you do not have a phone number, please leave a number where you can be reached

OK to Leave a Message? *

Yes No

Email *

No e-mail? Get one at Gmail.com
G-MAIL

Address *

Line 1

Line 2

City

State

Zip Code

Country

If you are homeless, please write homeless, and County

What services are you interested in? *

Mental Health Group Therapy Substance Use Group Therapy (non-DUI) Individual Therapy Employment Assistance Services for people who inject drugs Services for people involved in sex work HIV Prevention and Testing PrEP Navigation Care Management for people living with HIV Re-Entry Services

check all that apply

How did you hear about The Empowerment Program? *

Friend / Family member Healthcare Provider Probation / Parole Officer Website / Internet Outreach Provider Flyer / Brochure Other

check all that apply

If Other: *

Are you on Parole? *

Yes No

Are you on Probation? *

Yes No

If you were recently released from PRISON. when were you released? *

If you were recently released from JAIL, when were you released? *

If you were in the RISE Unit at Denver County Jail, when were you involved in the program? *

Comment *

Referring Agency Release of Information *

Max file size: 20MB

Submit

OUR MISSION: Holistically helping individuals build healthier lives from the inside out.

The Empowerment Program
1600 York Street
Denver, CO 80206
303-320-1989
FAX: 303-320-3987

©2020 The Empowerment Program. All rights reserved.

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