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Member Intake

Complete a quick and secure intake form so our team can learn more about your needs and connect you to the right support and services.

Start Intake

Our Intake Process

1

We Review Your Request

Once you submit the online form, our team reviews your information to better understand your health and support needs.

2

We Contact You

A team member will call, text, or email you within 1–3 business days to:

  • Learn more about your situation

  • Answer questions

  • Explain available services

  • See if you may qualify for programs through your Medi-Cal plan

Insurance & Eligibility Check

3

We verify your Medi-Cal health plan and determine if you may qualify for services like:​

  • Enhanced Care Management (ECM)

  • Community Supports

  • Housing Navigation Services

  • Wellness Support Programs

4

Initial Assessment

If eligible, we schedule an intake appointment by phone, video, in-office, or in the community.

During this visit, we talk about:

  • Your health conditions

  • Doctor appointments

  • Housing or food concerns

  • Transportation needs

  • Mental health support

  • Personal goals and challenges

5

Personalized Support Plan

Our team creates a personalized support plan based on your needs and goals.

Examples may include:

  • Coordinating doctor appointments

  • Connecting you to resources

  • Helping with benefits applications

  • Health education

  • Transportation support

  • Housing navigation assistance

6

Ongoing Support

Your care team stays connected with you and helps guide you every step of the way.

We may:

  • Follow up regularly

  • Help coordinate care with providers

  • Connect you to community programs

  • Help you stay on track with your health goals

  • Support you during difficult life situations

Intake Form

Please complete this short form so our team can better understand your needs and see if you may qualify for free support services through your Medi-Cal health plan.

Intake Form

Birthday
Month
Day
Year
Preferred Contact Method
Best Time to Contact You
Preferred Language
English
Spanish
Other
Do you currently have Medi-Cal with a Managed Care Plan?
Do you currently have any chronic health conditions?
Do you need help with any of the following?
What is your current living situation?
By submitting this form, I understand this is only a screening form. I give permission for Empower Health Antelope Valley to run my Medi-Cal eligibility and contact me regarding available programs and services.
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