Updated Intake Form 2023

Intake Form

This form is used to request services with Embracing Abilities under the Medicaid Waiver. We are able to provide services for individuals under the Family Supports and CIH waivers.
Who is submitting this form for the consumer?*

Parent/GuardianCase ManagerConsumer (self)EA Staff (BDS)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*

MaleFemale
Is this individual emancipated?*

YesNo
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*

SelfParent/GuardianPOAOther
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:*

EmailPhone Call
Services Selection

We have select therapy openings listed on our website in detail. Please refer to these listings to determine if your availability matches. https://www.embracingabilities.com/therapy-openings/
Which waiver is this individual currently receiving?*

Family Supports Waiver (FSW)Community Integration Habilitation (CIH)Private Pay (Therapy services only)
For therapeutic services, we have the following openings. Please select your choice.*

Recreational TherapyMusic Therapy - Daytime ONLYWe are not interested in Therapeutic Services.
The Social Tones group will meet every Tuesday from 10:30-11:30am at our North Clinic (8202 Clearvista Pkwy, Indianapolis, IN 46256). Do you have availability at this time?*

YesNo
The Creating Connections group meets every Thursday from 12:45-3:15pm at our North Clinic (8202 Clearvista Pkwy Indianapolis, IN 46256). Do you have availability at this time?*

YesNo
The Knead For Success group will meet every Tuesday from 10am-12pm at our West Clinic (6748 E US Hwy 36 Avon, IN 46123). Do you have availability at this time?*

YesNo
Please select the days of the week you have available for Behavior Management sessions:*

MondayTuesdayWednesdayThursday
Please select the times you are available for Behavior Management sessions:*

8am-10am10am-12pm12pm-2pm
Please select the days of the week you have available for Music Therapy sessions:*

MondayTuesdayWednesdayThursday
Please select the times you are available for Music Therapy sessions:*

9am-11am11am-1pm1pm-3pm
Please select the days of the week you have available for Recreational Therapy sessions:

MondayTuesdayWednesdayThursday
Please select the times of day you are available for Recreational Therapy sessions :

8am-10am10am-12pm12pm-3pm
Please select the times of day you are available for Recreational Therapy in Columbus on Mondays:

8am-10am11am-1pm2pm-4pm5pm-7pm
Are you interested in attending the DREAM Studio? (Day Program Location: Avon, IN Ages 18-40, accepting clients for Fall 2025)*

YesNo
Are you interested in a current advertised therapy opening? (please see website for a list of openings)*

YesNo
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 (Direct Support Professional - DSP) that you are wanting us to hire on your behalf to provide PAC, RSPO, or RHS care, please fill out the information below. We do not have a pool of staff to provide these services at this time.
Select the services you are interested in receiving:*

Participant Assistant Care (PAC)Respite Services (RPSO)Residential Habilitation Services (RHS)We are not interested in PAC, RSPO or RHS services.
Select the services you are interested in receiving:*

RespitePersonal Assistance Care (PAC)We are not interested in PAC or Respite services.
Support Staff Name 1*

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

Confirmation Emailexample@example.com
Do you have more caregivers to enter?*

YesNo
Support Staff Name 2

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

Confirmation Emailexample@example.com
Do you have more caregivers to enter?*

YesNo
Support Staff Name 3

First NameLast Name
Relationship to Consumer
Support Staff 3 Email

Confirmation Emailexample@example.com
Anticipated DSP Schedule

Please provide us with a tentative schedule that your Direct Support Professional might be working with the client on a weekly basis. If there are multiple shifts in one day, please list all anticipated shifts. If there are days of the week that you don't anticipate them working, please put N/A in the box. DSPs cannot work more than 40 hours in one work week (Monday-Sunday).
Sunday*
e.g. 7am-9am, 3pm-5pm
Monday*
e.g. 7am-9am, 3pm-5pm
Tuesday*
e.g. 7am-9am, 3pm-5pm
Wednesday*
e.g. 7am-9am, 3pm-5pm
Thursday*
e.g. 7am-9am, 3pm-5pm
Friday*
e.g. 7am-9am, 3pm-5pm
Saturday*
e.g. 7am-9am, 3pm-5pm
Waiver Team Member Information
Case Management Company*

Connections Case ManagementIPMGColumbus OrganizationCarestarUnity of IndianaInspire Case Management
Have you signed a choice list with your case manager?*

YesNo
A choice 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).
Case Manager's Name*
Case Manager's Email*
example@example.com
Does the consumer receive behavior support services through the waiver?*

YesNo
Behavior Consultant Name*

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

Case Manager/Choice ListFacebookFriend/Family MemberCaregiverCurrent Embracing Abilities familyGoogleOther
You will not be able to submit this form until you have selected at least one service.
OFFICE USE ONLY
Should be Empty:

Intake Form

Demographic Information

Primary Contact Information

Services Selection

Services Selection Cont.

Anticipated DSP Schedule

Waiver Team Member Information