Empact Parenting Program Registration - IN Medicaid Waiver Participants

Thank you for your interest in registering for an Empact Parenting Program!

Empact Parenting Programs -

Explore and discuss parenting styles, knowledge, beliefs, and behaviors
Teach proven communication and behavior management parenting tools
Help parents plan for the future
Encourage personal awareness
Improve family health, viability, engagement, and interactions
Connect parents with other parents

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* 1. Which program do you want to register to participate in?

Basics, February 21 - date of first zoom, 5-week virtual program for parents of all ages, Tuesday evenings at 7P, completes on March 21, 2023, $500 per parent

Basics, March 29 - date of first zoom, 5-week virtual program for parents of all ages, Wednesday evenings at 7P, completes on April 26, 2023, $500 per parent

Empact Parenting of Infants and Young Children, April 21-23st - In-person program in Indianapolis, IN, starts on Friday evening, goes all day Saturday and Sunday, parents may also complete Empact Parenting facilitator training and certification process, meals and snacks included during program; $900 per parent

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* 2. Client Information

First and Last Name of Client

DOB (MM/DD/YYYY)

Age of Client

Diagnosis

Last 4 digits of SS#

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* 3. Parent(s) Information

Name of Parent(s) *

Street Address

City/Town *

State/Province *

ZIP/Postal Code *

County *

Email *

Phone Number *

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* 4. How did you hear about this Empact Parenting program?

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* 5. Which race/ethnicity best describes you and your child? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

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* 6. How many parents/caregivers will be attending the Empact Parenting program?

Other (please specify)

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* 7. Please select your preferred language for your program workbook and materials

English

Spanish

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* 8. How will your registration be paid for?

Through the Indiana Medicaid Waiver

I am paying for myself

I am requesting a scholarship

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* 9. If you are on one of the IN Medicaid Waivers, please select the current Indiana Case Management Company that is serving this client

Carestar

Columbus

Connections

Inspire

IPMG

Unity

Not applicable

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* 10. If you are on one of the IN Medicaid waivers, please provide the Case Manager's Contact Information

Name of Case Manager

Email Address

Phone Number

PROGRAM NOTES

Parents participating in the virtual program must have internet access and device (computer, tablet, or phone) with a camera.
Parents participating in the virtual programs will be expected to complete 30 minutes of homework or self-study consisting of watching videos and completing exercises prior to the weekly facilitated zoom sessions.
All parents will receive an Empact Parenting program kit that will include a hard-copy workbook and other program materials.
Registered parents will receive more detailed information about their program.
If you need additional information or if you have questions, please check out our website at empactparenting.com or contact us at empactparenting@gmail.com.

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* 11. Please acknowledge the following statement:
I understand that once I have received the Empact Parenting program materials (hard-copy and access to online videos), this program is no longer refundable and my waiver will be charged at the scheduled completion of the program.

Yes, I acknowledge that I understand

THE FOLLOWING INFORMATION IS FOR PARENTS WITH ACCESS TO THE INDIANA MEDICAID WAIVERS OR MEDICAID MENTAL HEALTH WRAP AROUND SERVICES

PARENTS: Our Empact Parenting programs qualify as Family and Caregiver Training or FCAR that is part of the Community Integration and Habilitation and Family Support Waivers for the State of Indiana.

You DO NOT have to pay in advance for the program. Your waiver or service fees will be charged once the parenting program has completed. Since program participants receive access to hard-copy and online materials, this program is non-refundable.

In addition to completing this registration form, you will need to make sure that your Case Manager adds this program to your child's Medicaid Waiver plan. If you are on a waiver, please complete a pick list with 'The ALTRUIST Group' listed as the service provider. Please sign it and return it to your Case Manager.

MEDICAID WAIVER CASE MANAGERS: You will need to add this program to your client's PCISP by doing the following -
* Search for and select 'The ALTRUIST Group' from the pick-list. You may need to select Marion or Hamilton counties to find 'The ALTRUIST Group' as an option.
* Review the program information included above and on the program flyer to provide the justification for the client's parent's participation.
* Enter the date of the first zoom as the start date. Please enter the date of the final zoom as the last date.
* The ALTRUIST Group will charge the waiver once the program has completed.
* Please send the completed Service Authorization/Notice of Action document to: kristin@eeminds.org.

EXAMPLES FOR MEDICAID WAIVER CASE MANAGERS
* If your parent is attending the 5-week virtual program that starts on August 16th (ie. Start Date) and the final zoom is on September 13th (ie. the End Date), then you'd recognize the program for one (1) unit in September for $500 for the budget. Each parent that attends requires one unit to be entered. So, if both parents are attending, then you'd enter two (2) units in September and $1,000 for the budget.

* If your parent is attending the in-person program taking place during the weekend of September 9-11th (ie Start Date is September 9 and End Date is September 11) in Indianapolis, then you'd recognize the program for one (1) unit for September for $900 budget. Each parent that attends requires one unit to be entered. So, if both parents are attending, then you'd enter two (2) units in September and $1,800 for the budget.

To confirm registration to a program, please send the completed Service Authorization/Notice of Action document to: kristin@eeminds.org.

Empact Parenting Programs include -

Structured educational curriculum with videos and exercises
Facilitated parent-to-parent discussions
Parent workbooks and materials

Please make sure to click on the Done button to submit your Empact Parenting form!

Empact Parenting Program Registration - IN Medicaid Waiver Participants

Question Title

* 1. Which program do you want to register to participate in?

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* 2. Client Information

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* 3. Parent(s) Information

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* 4. How did you hear about this Empact Parenting program?

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* 5. Which race/ethnicity best describes you and your child? (Please choose only one.)

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* 6. How many parents/caregivers will be attending the Empact Parenting program?

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* 7. Please select your preferred language for your program workbook and materials

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* 8. How will your registration be paid for?

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* 9. If you are on one of the IN Medicaid Waivers, please select the current Indiana Case Management Company that is serving this client

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* 10. If you are on one of the IN Medicaid waivers, please provide the Case Manager's Contact Information

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* 11. Please acknowledge the following statement:I understand that once I have received the Empact Parenting program materials (hard-copy and access to online videos), this program is no longer refundable and my waiver will be charged at the scheduled completion of the program.

* 11. Please acknowledge the following statement:
I understand that once I have received the Empact Parenting program materials (hard-copy and access to online videos), this program is no longer refundable and my waiver will be charged at the scheduled completion of the program.