Thank you for your interest in the Indiana Pregnancy Promise Program. This referral form may be completed by individuals who use opioids and are pregnant, or recently pregnant, and would like support. Providers, family or friends may complete this form on behalf of another individual. The information provided will be protected and used to contact potential Pregnancy Promise Program participants. Once this form is completed, the individual will be contacted within two - three business days.

For a person to be enrolled in the Pregnancy Promise Program, they must meet certain criteria and agree to participate. Once a form is submitted, the Indiana Family and Social Services Administration and/or a Medicaid-managed care health plan (Anthem, CareSource, MDwise, MHS) will contact the individual to determine interest and eligibility.

Participation in the Pregnancy Promise Program is free, confidential and voluntary. Individuals may accept or decline participation at any time.

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