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, September 14 - date of first zoom, 5-week virtual program for parents of all ages, Wednesday evenings at 7P, completes on October 12, 2022; $500 per parent

Basics, October 13 - date of first zoom, 5-week virtual program for parents of all ages, Thursday evenings at 7P, completes on November 10, 2022; $500 per parent

Empact Parenting of Infants and Young Children, September 9-11th - In-person program in Indianapolis, IN, starts on Friday evening, goes all day Saturday and completes Sunday afternoon, 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. If you are on one of the Indiana 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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* 9. 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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* 10. 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. Our programs also qualify as training and education for unpaid caregivers as part of the Medicaid Mental Health Wrap Around Services.

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 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 parent's Cost Comparison Budget (CCB) 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 participation.
* Enter the last day of the program as the service completion date. If it is a 5-week program, then you would enter the date of the final zoom session.
* The ALTRUIST Group will charge the waiver once the program has completed.

EXAMPLES FOR MEDICAID WAIVER CASE MANAGERS
* If your parent is attending the 5-week virtual program that starts on August 16th and the final zoom is on September 13th (ie. the completion date), then you'd recognize the program for one (1) unit in June 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 June 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 completion date) in Indianapolis, then you'd recognize the program for one (1) unit for May 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 May and $1,800 for the budget.

Parent registration for the program will be confirmed once The ALTRUIST Group receives the Notice of Action (NOA) from the State.

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

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* 9. Please provide the Case Manager's Contact Information

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* 10. 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.

* 10. 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.