Updated Intake Form 2023

Embracing Abilities Intake Form

This form is used to request services through Embracing Abilities for individuals enrolled in the Medicaid Waiver program. We provide services under both the Family Supports Waiver (FSW) and the Community Integration and Habilitation (CIH) Waiver.
Who is submitting this form for the individual?

Other
Demographic Information

This is for the individual on the waiver who is seeking services.
Name of Individual on Waiver

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Is this individual emancipated?
If this individual is emancipated, but requires assistance completing forms we will need permission from the consumer permitting us to correspond with a third party (e.g. parents). Please complete the portion below with the consumer and have the consumer sign. Not completing this portion may cause delays in starting services. If this consumer is emmancipated and will complete forms and correspond with us themselves this portion can be left blank.
I, Consumer name , give Embracing Abilities permission to correspond and coordinate with First Name Last Name in order to begin services with Embracing Abilities. This includes permitting the above named individual to correspond with Embracing Abilities by email, in-person, and phone regarding my services and allowing this individual to complete necessary forms on my behalf. Date Signature
Last Four of SSN (Waiver recipient):
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Primary Contact Information

Parent/Guardian or Self
Parent/Guardian/Self:

First NameLast Name
Relationship to Consumer

Other
Parent/Guardian/Self Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian/Self Email

Confirmation EmailPlease be sure to enter an email that is checked frequently as we will send important updates and forms electronically to the email provided here. We recommend you add intake@embracingabilities.com to your contacts so emails do not go to a Junk/Spam folder.
Preferred Method of Communication:
Services Selection

We currently have select therapy openings available. Please review the detailed listings on our website to determine whether the available times and locations align with your schedule and needs: https://www.embracingabilities.com/therapy-openings/
Which waiver is this individual currently receiving?
For therapeutic services, we have the following openings. Please select your choice.
Please select the days of the week you have available for Behavior Management sessions:
Please select the times you are available for Behavior Management sessions:
Please select the days of the week you have available for Music Therapy sessions:
Please select the times you are available for Music Therapy sessions:
Please select the days of the week you have available for Recreational Therapy sessions:
Please select the times of day you are available for Recreational Therapy sessions :
Please select the times of day you are available for Recreational Therapy in Columbus on Mondays:
Are you interested in attending the Embracing Abilities DREAM Studio (Adult Day Program)? (Ages 18–40 | Now Accepting Clients for Fall 2026 | Location: Avon, IN)
Are you interested in one of our currently advertised therapy openings? (Please visit our website to view a list of available openings.)
Please list the therapy opening you are applying for.
(e.g: Music Therapy, Wednesday, 5:00-6:00pm)
Services Selection Cont.

If you have a preferred staff (Home & Community Support Professional - HCSP) that you are wanting us to hire on your behalf to provide PAC, RSPO, or RHS care, please fill out the information below. Embracing Abilities does not have a pool of available staff for these services.
Select the services you are interested in receiving:
Support Staff Name 1

First NameLast Name
Relationship to Individual
e.g. grandparent, family friend, etc
Support Staff 1 Email

Confirmation Emailexample@example.com
Do you have more caregivers to enter?
Support Staff Name 2

First NameLast Name
Relationship to Individual
e.g. grandparent, family friend, etc.
Support Staff 2 Email

Confirmation Emailexample@example.com
Do you have more caregivers to enter?
Support Staff Name 3

First NameLast Name
Relationship to Individual
Support Staff 3 Email

Confirmation Emailexample@example.com
HCSP Hour Guidelines

Please acknowledge that Home & Community Support Professionals (HCSPs) are limited to a maximum of 40 hours per work week (Monday–Sunday) and 16 hours per work day.
I understand that Home & Community Support Professionals (HCSPs) are limited to a maximum of 40 hours per work week (Monday–Sunday) and 16 hours per work day, and that any requested service hours must comply with this requirement.
Waiver Team Member Information
Case Management Company
Please notify your case manager to sign a choice list. A Choice List is a form provided by your case manager that outlines the available service providers in your area. After reviewing the list, you will initial and sign the form to indicate your choice of Embracing Abilities and authorize your case manager to share your information with us. Please note that selecting Embracing Abilities does not guarantee services, but allows us to recieve information.
Case Manager's Name
Case Manager's Email
example@example.com
Does the consumer receive Behavior Support Services (BSS) through the Indiana Medicaid Waiver?
Behavior Consultant Name

First NameLast Name
Behavior Consultant Email
example@example.com
Behavior Consultant Company
Comments/Questions
How did you hear about Embracing Abilities?

Other
You will not be able to submit this form until you have selected at least one service.
OFFICE USE ONLY
Should be Empty:

Embracing Abilities Intake Form

Demographic Information

Primary Contact Information

Services Selection

Services Selection Cont.

HCSP Hour Guidelines

Waiver Team Member Information