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?

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 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?
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 DREAM Studio? (Day Program Location: Avon, IN Ages 18-40, accepting clients for Fall 2026)
Are you interested in a current advertised therapy opening? (please see website for a list of 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. We do not have a pool of staff to provide these services at this time.
Select the services you are interested in receiving:
Select the services you are interested in receiving:
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?
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?
Support Staff Name 3

First NameLast Name
Relationship to Consumer
Support Staff 3 Email

Confirmation Emailexample@example.com
Anticipated HCSP Schedule

Please provide us with a tentative schedule that your Home & Community 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. HCSPs 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
Have you signed a choice list with your case manager?
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?
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:

Intake Form

Demographic Information

Primary Contact Information

Services Selection

Services Selection Cont.

Anticipated HCSP Schedule

Waiver Team Member Information