Youth intake

Motivated and Empowered Inc. Youth & Family Intake Form

Thank you for your interest in Motivated and Empowered Inc. Please fill out the following form to help us understand your needs and how we can best serve you.
Participant Name First Last
Gender:

MaleFemalePrefer Not to Say
Prefer not to say
School Attending
Grade Level
Address

Address

Street Address Line 2

CityState

Zip Code
Email Address
ParentGuardian Name First Last
Relationship to Participant
Phone Number
Email Address
example@example.com
Emergency Contact Name (First, Last):
Emergency Contact Number:
Relationship to Participant
Phone Number
Other
Does the participant have any medical conditions or allergies we should be aware of?
If yes please explain
Which Motivated and Empowered Inc. programs are you interested in? (Check all that apply)Workforce Development/Trade Education Respite/Transitional Housing Scholarship Opportunities

caseHousing AssistanceGuiding Stars: Mentorship program pairing students with mentors who provide support inacademics, life skills, and career exploration.Life Skills Workshops: Topics such as communication, goal setting, and decision-making.“It’s Personal” Hygiene Boxes: filled with essential items such as soap, toothpaste,deodorant, and more to support students in need. These boxes are offered completely free ofcost to schools, ensuring students have access to basic hygiene products to help them feelconfident and ready to succeed.After-School Programs (for boys and girls):Social-Emotional Learning (SEL) Support: Addressing self-awareness, empathy, andconflict resolution skills.Academic Tutoring (In-School): Tutoring for core subjects like Math, Science, and Reading.Violence Intervention and Reduction (In-School): aimed at addressing conflict, promotingpeaceful solutions, and reducing violence among youth. Through workshops, counseling, andmentorship, we equip students with the tools to resolve disputes non-violently, build emotionalresilience, and foster safer, more supportive school environments.Little Leaders AcademyLittle Leaders Academy is tailored for elementary-aged children, focusing on buildingfoundational skills for future success.M.E. BoutiqueThe M.E. Boutique provides clothing and personal care items to youth in need, ensuring theyhave the essentials to feel confident and prepared for school and life.P.E.A.R.L AcademyP.E.A.R.L Academy (Preparing, Educating, Achieving, and Reaching Leadership) is focused onleadership development for young girls.Pumped, Promised, PolishedThis program focuses on building self-esteem, confidence, and life skills in young girls.BloomNourish: Empowering Expectant MothersBloomNourish is designed to support expectant mothers throughout their pregnancy journey andbeyond.TinyLives Thrive: Infant Wellness InitiativeTinyLives Thrive focuses on the health and wellness of infants, providing resources and supportto ensure a healthy start.Crisis Intervention• Service Provided: Immediate crisis intervention for students experiencing acute mentalhealth crises, including suicidal ideation, severe emotional distress, or aggressivebehavior.Intensive Case Management• Service Provided: Coordination of care for students with complex needs, includingworking with the school, family, and external providers to ensure comprehensive support.The case manager will also collaborate with the Crisis Response Team for ongoingmonitoring of students after a crisis event.Effective Parent CommunicationThis program helps parents and caregivers develop effective communication strategies with theirchildren
Referring Agency Name, Contact Person, Phone and Email:
Does the participant have an Individualized Education Plan (IEP) or special educational needs?
If yes please explain
What are the participants goals or areas where they would like support
How did you hear about Motivated and Empowered Inc
Facebook, Google, Other
Photo/Video Release: I consent to Motivated and Empowered Inc. using my child's image in photos or vide

YesNo
Medical Release: In case of emergency, I authorize the staff of Motivated and Empowered Inc. to seek medical care for my child.

YesNo
Program Participation: I give permission for my child to participate in Motivated and Empowered Inc. programs and/or services.
ParentGuardian Signature

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Date

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Date
For any questions or concerns, please contact us at bcrawford@motivatedanempowered.com or call (440)
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