Empower - Empowering Individuals, Families, and Communities.


Client Intake Forms

Please Fax all forms to 612.781.2428

You will be assigned to a therapist who will contact you or your worker within 48 hours. The therapist will schedule an intake session


Release/Exchange of Information

Authorized Consent to Treatment and Payment

Empower Therapeutic Support Services Referral Form

Clients Rights Responsibilities

FORM 23000

Payment Options
Sliding Scale
General Medical Assistance
United Behavior Health (Medica)
Behavioral Health Provider
County Reimbursements (call to inquire)


If paying by PayPal, please use cweatherspoon@empowerfam.com as the email address.


If you would like more information about our fees or our practice, please contact us.