Name *

First Name

Last Name

Phone

(###)

###

####

Is it safe for an Empower Tehama advocate to call you at this number anytime? (If the answer is "No" or blank, we CANNOT call you. Please provide a SAFE email below, or call us at 530-528-0226.)

Yes

No

Is it safe for an Empower Tehama advocate to email you at this address anytime? (If the answer is "No" or blank, we CANNOT email you. Please provide a SAFE phone number above, or call us at 530-528-0226.)

Yes

No

How would you prefer we contact you? (If you have not indicated either contact method as being safe for use to contact you, we will not be able to contact you. If this is the case, please call our 24-Hour Crisis Hotline at 530-528-0226) *

NOTE: If a reply from us by email or phone may put your safety at risk, please call our 24-Hour Crisis Hotline at 530-528-0226 or drop in at our Business Center between 9AM and 4PM M-F at a time that is safe for you.

Email

Telephone

Either one is fine

Neither, I will call Empower Tehama's 24-hour crisis hotline or drop-in at the Business Center.