EMPOWERED TO STAND HEALTH SERVICES

CATHEDRAL CHRISTIAN ACADEMY/EMPOWERED TO STAND HEALTH SERVICES
ESHS HAS PARTNERED WITH MENTAL HEALTH THERAPY ORGANIZATIONS TO BEGIN THE INTAKE AND ASSESSMENT PROCESS FOR YOUR CHILD TO RECEIVE THERAPY AND POSSIBLY PRP SERVICES THROUGH EMPOWERED TO STAND HEALTH SERVICES. PLEASE COMPLETE THE FOLLOWING INFORMATION ON THE FORM TO INITIATE THE PROCESS.
Parent(s) Name (s)*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Parent's Email
example@example.com
Child's Name*

First NameLast Name
Child's Date of Birth
PLEASE ADD ADDITIONAL CHILD(REN) BELOW.
Child's Name

First NameLast Name
Gender
Date of Birth
Child's Name

First NameLast Name
Gender
Date of Birth
HOUSEHOLD SIZE*
Is your family income less than the amount in column A (Free Eligibility) ?
Is your family income less than the amount in column B (Reduced Price Eligibility)?
Select your child(rens) grades. Hold down the CTRL key to select multiple grades*
Are any of your children eligible to receive medical assistance?*

YesNo
Please Provide Name of Medical Insurance
Please Provide Medical Insurance Number
Are you receiving assistance under the Temporary Assistance to Needy Families (TANF) program?
MRS. TAYLOR FROM EMPOWERED TO STAND WILL CONTACT YOU SHORTLY IN ORDER TO GATHER ADDITIONAL INFORMATION IF NECCESSARY.

**YOUR SIGNATURE ACKNOWLEDGES YOUR AGREEMENT FOR YOUR CHILD TO BEGIN THE INTAKE AND ASSESSMENT PROCESS TO DETERMINE WHETHER OR NOT HE/SHE WILL BE RECEIVING MENTAL HEALTH SERVICES THROUGH THE PSYCHIATRIC REHABILITATION PROGRAM (PRP) PROVIDED BY EMPOWERED TO STAND HEALTH SERVICES.
Signature

Clear
Should be Empty:

CATHEDRAL CHRISTIAN ACADEMY/EMPOWERED TO STAND HEALTH SERVICES