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Empowerment Center Inc

705 E Franklin Blvd


Gastonia, NC 28054

Intake Contact Number: 704-594-2382 Office Number 704.215.5585


Email: quetonnia@empowermentcenternc.com
Fax:704.565.4149

Intake
Application
Intake Date: _________________
Last Name: _______________________First Name__________________

DOB: _______________ Age: ___________ Social Security Number: ________________

Highest Level Education: _________________

Contact Number: ______________________

E-mail: ____________________________________________________________________

Emergency Contact: _________________ Emergency Number:


_____________________

 
Are you on probation

Yes _____ or  No _____

Do you have any outstanding warrants

Yes _____ or  No _____

Do you have any future court dates

Yes _____ or  No _____

Do you have any future medical appointments (doctor, dentist,


therapist, counselor etc…)

Yes _____ or  No _____


Are you a  registered sex offender

Yes _____ or  No _____

Are there any future events that would interfere with your 21 day
stay here at the Empowerment Center

Yes _____ or  No _____

Will you need to stay longer than 21 days

Yes _____ or  No _____

 
Do you have private Insurance or Medicaid _____________________________

Yes _____ or  No _____

Are you a child, youth or young adult

Yes _____ or  No ______

Are you a teenage parent

Yes _____ or  No _____

Are you being evicted with kids

Yes _____ or  No ______

Is this a domestic violence referral

Yes  _____or  No_______

Are children involved

Yes _____ or  No _______

Ages: ___________

Are you currently using drugs

Yes _____ or  No _____

When was the last time you used drugs or abused prescription drugs

_____________________________________________________________________________

Are you in rehab

Yes _____ or  No ______


Do you want to receive treatment

Yes _____ or  No ______

Are you HIV positive

Yes _____ or   No ______

Have you been exposed to COVID 19

Yes ______ or No ______

Have you tested positive COVID 19

Yes _____ or No _______


Have you been diagnosed with any other communicable disease or
illness

Yes _____ or  No _____

Are you pregnant

Yes _____ or  No ______

Any known allergies

Yes _____ or  No _____

Allergic to any medications

Yes _____ or No _____

 
 
Any additional information

______________________________________________________________________________
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How were you referred

______________________________________________________________________________
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By signing this intake form, I am consenting to services offered by
the Empowerment Center, INC. I do not hold the organization, staff,
volunteers, Board of Directors or Executive Director liable for any
wrong due to false information on my behalf.

If I have a problem or concern, I will follow the chain of action before


leaving the facility and or program.

I will comply to the terms and the policy of Empowerment Center,


INC.

I understand that I will not be held against my will. I can leave the
program and shelter at any time. I also understand that I may not be
able to receive services in the future if I have misused or abused
any privileges at Empowerment Center, INC.

This form stands as an acceptable sign release form to enable me


the treatment and service that I need.

I can use this form to get any medical treatment and or assistance
through NC Department of Health and Human Services, (DSS), Social
Security, Education, and all other assistance to ensure my safety
and wellbeing while being part of this program and shelter.

I agree to all services offered by the Empowerment Center, INC.

 
Signature: _____________________________________________ Date: ___________

Third Party Signature: ________________________________ Date:


______________

 
 
 
 
 
 

For Office Use Only

Chronically Homeless Yes _____ or No _____

HUD adopted the Federal definition which defines a chronically


homeless person as “either (1) an unaccompanied homeless
individual with a disabling condition who has been continuously
homeless for a year or more, OR (2) an unaccompanied individual
with a disabling condition who has had at least four episodes of
homelessness in the past three years.”

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Executive Director ________________________________________ Date


_______________

Site Supervisor ____________________________________________Date


_______________
Case Manager _____________________________________________ Date
_______________