Intake Form
This form is used to request services under the Medicaid Waiver. We are able to provide services in Tippecanoe County, Indiana under the Community Integration Habilitation (CIH) or the Family Supports (FSW) Waivers.
Name of Individual on Waiver
*
First Name
Last Name
Gender
Please Select
Male
Female
N/A
Contact Number:
Format: (000) 000-0000.
E-mail
example@example.com
County of Residence
Please Select
Tippecanoe County
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have caregivers that you would like to have as staff?
Yes
No
Parent or Guardian Information
Parent/ Guardian
*
First Name
Last Name
Are you the legal guardian?
*
Yes
No
Email
*
Contact Number
*
Format: (000) 000-0000.
Case Manager Information
Case Manager's Name
First Name
Last Name
Agency Name
Please Select
IPMG
Connections Case Management
Columbus Organization
Carestar
Inspire Case Management
Unity of Indiana
Email
Contact Number
Format: (000) 000-0000.
Please tell us a little bit about the services that you are needing and how many hours per week.
How did you hear about Plans to Prosper?
Case Manager
Pick List
Facebook
Caregiver
Friend/ Family Member
Other
Submit
Should be Empty: