Empowered Resolve – General Intake Form
Please complete this form to begin the intake process. Once received, a member of our team will follow up with next steps, including any required consents or documents based on your selected service.
Client Information
Name
*
First Name
Last Name
Business Name (If any)
Phone Number
*
Please enter a valid phone number.
E-Mail
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Address (If any)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Reason for Contacting Us (Check all that apply)
*
Please Select
Guardian ad Litem (GAL)
Mediation Services
Educational Advocacy / School Consultation
Small Business Consulting
Medicaid Audit or Insurance Billing
General Professional Consulting
Mobile Notary Services
Professional Development
Brief Description of Your Situation or Goals (What prompted you to reach out?)
Referred By
Self
Attorney
DCF/Social Worker
School or Provider
Internet/Google
Social Media
Other
Other:
Availability for Appointments
Preferred Days/Times:
Any deadlines we should be aware of?
Initial Acknowledgments
(Check to confirm)
Name
First Name
Last Name
Signature
*
Date
-
Month
-
Day
Year
Date
Completed Form
*
Please Select
Client
Consultant
Free Consultation Completed
Please Select
Yes
No
Submit
Should be Empty: