communityempowermentservices.com - Request an Appointment Form

Patient Name*

First NameLast Name

Patient DOB*

Date

Patient Sex*

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.

Select which apply*

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

Select which apply*

Adult patient, this is my emailTeen patient, this is my emailMinor patient, this is email of parent/guardian

Requested Services*

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?*

If full, would you like to be added to our waitlist?

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.