Enrollment (Caregiver) - HMH Autism Program

Welcome to the Hackensack Meridian Children's Health EmpowerU Program: a resource for you throughout your journey caring for a loved one with autism. The information you receive will be related to the topics you express interest in, such as:

Autism education and awareness (ex: sleep, behavior, hygiene, and safety)
Assistance for the newly diagnosed
Caregiver stress and emotional support
Personalized resources

We encourage you to read each individualized message, and to let us know how else we may help you along your journey.

Please complete this short survey to enroll into the EmpowerU Program:

Legal Age

By clicking this box, I certify that I am 18 years of age or older and the parent/guardian/caregiver of a patient with an autism spectrum disorder (ASD) diagnosis (if you are under age 18, please have your parent/legal guardian complete this form- they will be able to enroll you into the program).

Your Name*

First Last

Your mobile number*

My child is a patient at*

How did you hear about this program?*

What is the name of the provider?*

Please specify:*

Zip Code*

Date of entry into the program*

Patient Name*

First Last

Patient's Date of Birth*

Hidden

Age

When was the patient diagnosed with ASD?*

If you don’t know the exact day, please use the first day of the month you believe your child was diagnosed.

Insurance Provider

Patient's Gender

(Your responses are confidential. We use your answers to ensure we deliver the content that best supports your personal needs).

Patient’s sex assigned at birth:

Female
Male
Unknown
Not recorded on birth certificate
Choose not to disclose
Uncertain

Patient’s Race and Ethnicity

(Select all that apply)

Race

American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
Prefer not to disclose

Please specify:

Ethnicity

Hispanic or Latino
Not Hispanic or Latino

This program has content to support caregivers of children with ASD as well as the patients themselves (minors over the age of 12). With your consent, we can enroll your child into a program which will provide age-appropriate resources and support directly to their mobile phone. With whom will we be communicating during the program?*

Caregiver & Patient (Enrolling patient only an option if child older than 12)
Caregiver only (Child is under 12 and/or parent does not want child to enroll)

Minor Patient’s mobile number*

Consent*

Parent consents to their minor being enrolled into the patient facing components of the program (parent understands that by providing child’s mobile number, HMH will be sending messaging and educational/support resources to child’s mobile phone.

How strongly do you agree with this statement: “I am well supported with resources and information I need to effectively navigate my child’s ASD Diagnosis”*

Strongly agree
Agree
Neither agrees nor disagree
Disagree
Strongly disagree

How strongly do you agree with this statement: “I am confident in my ability to manage my child’s ASD diagnosis”*

Strongly agree
Agree
Neither agrees nor disagree
Disagree
Strongly disagree

Enrollment Form