SINGLE PARENTS OF POWER

Please fill out ALL information below if applicable. This will help our agency to better assist you.

Client Name

Today's Date

Phone Number:

Email Address:

Gender

Female
Male

Date of Birth

Services Requested

Domestic Violence - for victims
Domestic Violence - for offenders
Parenting
Co-Parenting (Please let us know your partners name in the box below)
Anger Management
Individual Counseling
Couples Counseling (Please let us know your partners name in the box below)
Conjoint Counseling (Please let us know your partners name in the box below)
Substance Abuse Counseling
Other

Please put your partners name here if you chose co-parenting, conjoint counseling or couples counseling. OR If you chose 'Other', please let us know the type of counseling you wish to receive

Primary Language

English
Spanish
Other

If 'other', Please let us know your primary language

Do you have Medi-Cal or LA Care? (BE AWARE: Classes are FREE if you have straight Medi-Cal or LA Care. Otherwise you will be charged a $50 fee per session. Once again: We ONLY accept straight Medi-Cal or LA Care insurance)

YES: I have straight Medi-Cal or LA CARE
NO: I do NOT have medi-cal and will pay $50 per class

Please Provide us with your days and hours of availability. This information will allow us to place you with a therapist or class that works with your schedule

Our registration fee is $50.00 per class. However, if you are unable to pay the registration fee at this time, we do offer a payment plan. Would you be interested in a registration fee payment plan?

Yes
No

After pressing submit, you will receive a follow up email within 48 hours from Single Parents of Power. Please make sure your email address is correct and thank you for registering with Single Parents of Power!

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