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Making Connections! Empowering Lives! Impacting the Future!

@ Phone MailContact Us

Phone: 770.971.7881
Fax: 770.971.7882
Email:

Parent Information
Parent Name:
Address:
City:
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Phone: (with area code)
Cell Phone: (with area code)
Work Phone: (with area code)
Student Information

Please indicate Name, Age, Grade, Teacher and School for each child who requires our services:

What service and specific subject area are you requesting for your child(ren)? 

Have you tried other interventions prior to coming to Empower Educational Services?

If so, please explain:

Does(Do) your child(ren) have any special needs? 

If so, what are they and how is your child's school servicing those needs?

Referral Information

How did you hear about us?
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