Get Started - Empowerment Program, Inc.

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1600 York Street
Denver, CO 80206

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

Fill out the Pre-Intake Form
or Call 720-850-7500

An Intake Specialist will contact you within 2 business days

PRE-INTAKE FORM - Contact an Intake Specialist to Enroll

* Indicates required field

Name *

First

Last

Date of Birth *

Month/Day/Year

Gender Identity *

cisgender - your gender matches your assigned birth sex

What Pronouns Do You Use? *

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) *Brief Individual Therapy Acupuncture & AcuDetox Services for people who inject drugs HIV Prevention and Testing PrEP Navigation Care Management for people living with HIV Re-Entry Services Other

check all that apply

* Please note, there may be a waitlist for Individual Therapy

If Other, what are you interested in? *

How did you hear about The Empowerment Program? *

Project: ELEVATE 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 / Probation? *

Yes, I am on Parole Yes, I am on Probation No, I am not on Probation or Parole

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

If Project: ELEVATE, Care Manager Name: *

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

Any questions or concerns about enrolling, please e-mail our Intake team: intake@empowermentprogram.org

If you are an agency provider want to make a referral, click HERE.

Make a referral

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

The Empowerment Program
1600 York Street
Denver, CO 80206
303-320-1989
FAX: 303-320-3987
info@empowermentprogram.org

©2020 The Empowerment Program. All rights reserved.

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