Empowering Consultants Group - New Tutor Intake Form

New Tutor Intake Form

Welcome to the Empowering Consulting Group (ECG) Provider Portal. This form is the first step in the credentialing process for independent professionals seeking to provide services under the California Self-Determination Program (SDP).

By completing this enrollment, you are entering our active referral network. ECG serves as the administrative bridge between your specialized expertise and the fiscal requirements of the Regional Center and Financial Management Services (FMS). Please ensure all information is accurate to prevent delays in billing authorization.

Note: ECG utilizes a standardized reimbursement schedule based on authorized California SDP service codes. Specific case rates will be discussed during the matching interview based on the client’s approved Spending Plan.

First Name

Last Name

Mobile Phone

Address

Time Zone

Availability

Add Row

Photo Upload a square image (ie. 200px x 200px) in .jpg or .png format. Maximum size 250kb.

Website/Portfolio Link

File Upload: Please upload a Resume, Teaching Credential, or Certification

Bio

Primary Subject Expertise:

If you operate under a business name, please provide it here.

Business Entity Type:

Please describe your experience with specific learning disabilities or assistive technologies.

Minecraft Education Experience: ExpertFamiliarInterested in Learning

I understand that I am joining a professional network as an Independent Contractor and am not an employee of Empowering Consulting Group. I understand that I am joining a professional network as an Independent Contractor and am not an employee of Empowering Consulting Group.

I agree to utilize the Teachworks portal for session logging and documentation as required by the California Regional Center and the client’s Financial Management Service (FMS). I agree to utilize the Teachworks portal for session logging and documentation as required by the California Regional Center and the client’s Financial Management Service (FMS).

I agree to maintain the privacy and HIPAA-level security of all client data shared within this portal. I agree to maintain the privacy and HIPAA-level security of all client data shared within this portal.