Partnership | EMPOWERED LIVING SOLUTIONS

Organization Name:*

Full name:*

Phone number:*

Email:*

Do your clients typically require *

Independent living

Personal care/clinical services

Preferred method of collaboration:

Monthly meetings

Referral system

Joint events

Services you provide

Regions you serve (Cities and/or Counties)*

Interest area*

Referral partnership

Housing collaboration

Support sevices

Other

If "Other" explain

Short answer

Additional comments

Disclaimer & Attestation: By submitting this form, I certify that the information provided is true, accurate, and complete to the best of my knowledge. I understand that Empowered Community Living provides housing-only, peer-supported independent living and does not offer meals, caregiving, supervised medication, medical care, or clinical services. Participation is by program agreement, not a landlord-tenant lease. I authorize Empowered Community Living to contact me by phone, email, or text message regarding housing, referrals, or program participation. I may opt out of communications at any time by replying STOP or by contacting Empowered Community Living directly.*

I agree to the above disclaimer

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