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
A pick list is the form your case manager will present to you to review available companies in your area. You will initial and sign this form and return to your case manager to select Embracing Abilities and authorize your case manager to send us information about this consumer (it is not a guarantee of services).
You will not be able to submit this form until you have selected at least one service.