Empowered Services · Customer Intake Form

Let's build a care team around what matters.

Start with the basics so your local care team knows how to reach you. Then, if you want, add service, schedule, and matching details so we can prepare for the first conversation.

Get started in about 1 minute
All 36 Oregon counties
No pressure · No commitment
Usually 1–2 business days

Empowered Services provides Oregon I/DD services through authorized plans. We do not determine eligibility or authorize services or hours. Learn about services.

Form updated October 17, 2026 · Revision 1

Step 1 of 5 · Get started We capture your contact request before asking for detailed support information.

1. Start 2. Services 3. Schedule 4. Match 5. Review

Step 1 · About 1 minute

Start your intake.

Just the basics: who is reaching out, how to contact you, and which Oregon county needs support.

Who is filling out this form? *

MyselfI am looking for support for me.

Parent or guardianI am seeking support for my child or ward.

Family member / supporterSibling, spouse, adult child, friend, or supporter.

Case Manager / Services CoordinatorI am referring someone I support.

Someone elseAnother person helping with the request.

Choose the option that best describes you.

First name *

Last name *

How should we contact you? *

Best time to reach you Optional

Phone

Required for text or phone contact.

Required if email is your preferred contact method.

Preferred language for us to use when contacting you Optional

Oregon county where support is needed *

This routes your request to the right local care team.

No detailed support information is needed yet.

When you continue, Empowered can save this contact request first. The remaining questions help the care team prepare for follow-up.

Prefer to call? (503) 855-3581

Your intake is underway.

Add a few details so the care team can prepare for your request.

Step 2

Tell us about the person and the support you are exploring.

Use initials if you prefer. Exact plan details can be reviewed later with the care team.

About the person receiving support

We’ll use the relationship you selected in Step 1 so you do not have to answer the same question twice.

First name or initials of the person receiving support *

If this is you, we can use your name from Step 1.

Date of birth Optional

If provided, we calculate age and age group for age-restricted service choices. DOB is saved in restricted staff details and excluded from compatibility analysis. If left blank, choose an age group instead.

Age group *

Choose an age group if you prefer not to provide date of birth.

Support ZIP code Optional

Helpful for local matching and care-team routing within larger counties.

Are Oregon I/DD services already set up? *

It is okay to be unsure. Empowered can explain the provider side and help identify the right next step.

Current DSP/PSW situation *

ISP / ONA status *

No upload is needed here. Your ISP/ONA and authorization determine the services, staffing, setting, and hours that can be provided.

Case Manager / Services Coordinator Optional

Coordinator phone or email Optional

What support are you interested in? *

Choose all that apply, or choose “Not sure yet.” These are examples, not an authorization.

In-home and community care (Attendant Care)

Relief Care

On-the-Job Attendant Care

Community / group support (Day Support Activities) (adults)

Transportation (adults)

Not sure yet — help me understand the options

Do you already know someone you would like as the caregiver or DSP? *

YesI already have someone I trust.

NoI would like help finding a DSP.

Not sure yetI want to talk through both options.

You can change this later. Choosing “Yes” does not start employment paperwork yet.

Plan-based services: Empowered Services does not determine I/DD eligibility or authorize hours. Your approved ISP/ONA and authorization determine what can be delivered.

Support needs and ISP goals

What support needs and goals are included in your ISP or existing support instructions? Include behavior or emotional support if relevant.

Optional. Describe relevant goals and everyday support in your own words. No plan upload, diagnoses or private medical details are needed. Existing instructions guide preparation; this is not a separate behavior-support service.

Contact arrangements for your Care Team

These details are for follow-up, separate from the hours when support is needed or offered.

Which days and times are best for us to contact you?

Use local time where you are. Add up to seven contact windows.

Day	From	To
Day 1	From 1	To 1
Day 2	From 2	To 2
Day 3	From 3	To 3
Day 4	From 4	To 4
Day 5	From 5	To 5
Day 6	From 6	To 6
Day 7	From 7	To 7

Who else may we discuss your support with?

Step 3

What would support need to look like in real life?

Broad availability is enough. Exact authorized hours and the final schedule can be worked out later.

Weekly calendar

Use local times where support takes place. Enter exact times if known, or choose parts of the day. These are reported preferences, not assigned shifts.

Your answer

Available or requested from

Until (leave blank if ongoing)

Select the hours you want on each day. Select an hour again to clear it. For partial hours, broad preferences or overnight ranges, use the exact-time controls below.

Exact times and day preferences

Temporary changes or unavailable dates (optional)

About how many hours of support are you looking for each week?

Your answer

Customer service location

Confirm where the customer will receive support. The county below comes from your service-location answer, not the contact person’s residence.

Your answer

When are you hoping to start? *

How flexible is the schedule? Optional

Anything important about timing? Optional

Anything that should affect follow-up priority? Optional

There are gaps in current services

Current caregiver/support may be unavailable

Family or caregiver is feeling overwhelmed

There are current safety concerns

Empowered Choice — your proposed coverage / Su propuesta de apoyo

Your estimate does not confirm coverage or remove hours from matching. Both people and the Care Team must confirm the arrangements. / Esta estimación no confirma la cobertura ni reduce las horas por cubrir; ambas personas y el equipo deben confirmarla.

How much of your support would your chosen caregiver cover? / ¿Qué parte del apoyo cubriría su cuidador?About how many hours each week would they provide? / ¿Cuántas horas por semana brindaría?

Check blocks only if the whole block works. Leave uncertain days blank or choose “Not sure.” The Care Team will confirm exact times. / Marque un bloque solo si puede cubrirlo completo. Si no sabe, déjelo en blanco o elija “No sé”.

When would your chosen caregiver cover support? / ¿Cuándo brindaría apoyo su cuidador?
Day / Día	6–10 am	10 am–2 pm	2–6 pm	6–10 pm	10 pm–6 am (+1)	Unavailable / No disponible	Not sure / No sé
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Start date, if known / Fecha de inicio, si la sabeTime zone / Zona horaria

Empowered’s scheduling cap is 35 hours across all Empowered work. The Care Team checks this in HUB and payroll. Human connection is not scored. / El límite de programación es de 35 horas entre todos los turnos de Empowered. El equipo lo verifica en HUB y nómina. La conexión humana no se puntúa.

Your chosen caregiver

Start with the person you trust. Empowered Services handles the agency/employment steps if the person is eligible and completes required onboarding. You can add other caregivers during follow-up.

Caregiver full name *

Relationship Optional

Do they live in the same residence? *

Caregiver phone or email Optional

Finish your intake first. After you submit, we’ll show the official caregiver application link so your chosen caregiver can complete their employment step separately.

Corporate Office

Phone Number

Let's build a care team around what matters.

Start your intake.

Tell us about the person and the support you are exploring.

What would support need to look like in real life?

Exact times and day preferences

Your chosen caregiver

Need Empowered to help find a DSP?

Not sure which caregiver path fits?

Match details for your Care Team

Care Team preparation

Review and send to your care team.

Your intake was received.

Next step for your chosen caregiver

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