communityempowermentservices.com - Request an Appointment Form

Patient Name

First NameLast Name

Patient DOB

Date

MaleFemaleUnknown

Name of Parent for Minor Patient

Write "N/A” if Patient is 18+ years old

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Adult patient, this is my phone numberTeen patient, this is my phone numberMinor patient, this is phone number of parent/guardian

Email Address

example@example.com

Adult patient, this is my phone numberTeen patient, this is my phone numberMinor patient, this is phone number of parent/guardian

Individual Counseling – Child or TeenIndividual Counseling – Adult 18+Couples CounselingFamily CounselingMedication Management – Child or TeenMedication Management – Adult 18+

In short, what issue or concern are you experiencing prompting this appointment request?

Primary Insurance Carrier

To which of our offices do you live nearest?

What is your preference for treatment format?

YesNo

How did you hear about us?

Non-Emergency Use Only – Important Safety Notice

This appointment request form is intended for non-emergency outpatient mental health services only. Community Empowerment Services does not provide crisis intervention or emergency care through this form.

If you or your child are experiencing a mental health emergency, thoughts of self-harm, or are in immediate danger, please do not use this form. Call 911, go to the nearest emergency room, or contact the 988 Suicide & Crisis Lifeline (call or text 988) for immediate support.

Submitting this form does not create a therapeutic relationship and does not guarantee immediate services. Our administrative team will review your request and follow up as availability allows.