Noble Intake Application

Noble Intake Application

2026
Date of intake:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please note that this form may take 30 to 90 minutes to complete. Please have Medicaid & Social Security cards, Health information, doctors, and medication information accessible.

You are encouraged to SAVE this document as you work through it. You may save the document at any time using the SAVE option at the bottom of each page. You will return to the document using a link that will be emailed to you.

If at anytime you have questions, concerns or comments please reach out to Brianna Sierakowski, Noble Intake Coordinator at b.sierakowski@mynoblelife.org or at (317) 907-8134.

Our Mission
To expand opportunities and enhance the quality of life for people with disabilities and their families through individualized services.

Our Vision
A world in which children and adults of all abilities live out their dreams in a community that embraces their contributions and recognizes them as fully participating members of our society.

Our Core Values
Everything we do is shaped by our Core Values:

PEOPLE FIRST- We believe that all people with intellectual and developmental disabilities are defined by their own strengths, abilities and inherent value, not by their disability.
EQUALITY- We believe that people with intellectual and developmental disabilities are entitled to the respect, dignity, equality, safety, and security accorded to other members of society, and are equal before the law.
COMMUNITY- We believe that people with intellectual and developmental disabilities belong in the community and have fundamental moral, civil and constitutional rights to be fully included and actively participate in all aspects of society.
SELF-DETERMINATION- We believe in self-determination and self-advocacy. People with intellectual and developmental disabilities, with appropriate resources and supports, can make decisions about their own lives and must be heard on issues that affect their well-being.
INCLUSION- We believe that society in general, and Noble in particular, benefit from the contributions of all people without regard to characteristics like race, ethnicity, religion, age, national origin, sexual orientation, gender, disability, marital status and veteran status.

Charting the LifeCourse:
- Foundation
- Infographic
Primary Service Requested:

Other
Are you interested in other Noble services?
Additional Services you are interested in: (Select all that apply)

Other
Adult Day Services (ADS)

Adult Day Services encompasses the health and social needs of an individual. Individuals who select ADS typically have greater medical and health needs than someone who may select Day Habilitation Group.

In order to receive ADS services an individual must receive an assessment (Adult Day Service Level of Service Evaluation Form, completed by the Waiver Case Manager) to determine the Level of Service needed.

Noble Provides ADS at its Noble East location at 7701 E 21st Street, Indianapolis, IN 46219. ADS is separate from the Day Habilitation Program.

Day Habilitation Group Services: (DHG)

Habilitation should support individuals to build and retain skills that support independence, self-advocacy, social connections, and meaningful community participation. Noble’s Person-centered support should reflect the consumer’s goals, interests, and PCISP and may include integrated recreation and public events, skill-building through hobbies, volunteer opportunities, and assistance developing and maintaining relationships.
- Noble provides DHG services in a variety of settings and locations:
  - East: 7701 E 21st Street, Indianapolis, In
  - Campus- Noblesville: 216 Lakeview Drive, Noblesville, In
  - Campus- Mary Rigg Community Center
  - Campus: Garfield Park
  - Career Exploration Group: 50 S. Shelby, Indianapolis, In - Focus is on exploring, preparing and obtaining employment.
  - Noble Art: 5011 W 16th Street, Speedway, IN 46224
What days and times do you prefer to receive services:
Please note what the individual would like to achieve by attending Noble. Please note any steps or information that are important in the individual obtaining the goal. For example, if the individual would like to work on exercising 2 times a week. Note what kind of exercises they enjoy participating in along with the type of support staff will need to provide. (Verbal prompts, physical assistance, demonstration)
Personal Information
Full Name:

First NameLast Name
Nickname:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Individuals Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Individuals Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Individuals Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:

Other
Email Address:
example@example.com
Marital Status:

Other
Spouse Name:

First NameLast Name
Spouse Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Spouse Email:
example@example.com
Last 4 digits of the Individuals Social Security Number:
Do you have a physical copy of your Social Security Card?
Social Security Number: (Employment)
If you decline enter
Do you have a current Driver's License or State ID card? (Employment/ Residential)
DL/State ID- Expiration Date:
Contacts
Contact(s): (Select All that Apply)

Other
Is Mother's address the same as the Individual?
Mother Name:

First NameLast Name
Mother Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Mother Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Mother Email:
example@example.com
Is Father's address the same as the Individual?
Father Name:

First NameLast Name
Father Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Father Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Father Email:
example@example.com
Primary Emergency Contact:

First NameLast Name
Relationship:
Primary Emergency Contact Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Emergency Contact Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Primary Emergency Contact Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Primary Emergency Contact Email
example@example.com
Residential Provider Name:

First NameLast Name
Relationship:
Residential Provider Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Residential Provider Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Residential Provider Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Residential Provider Email:
example@example.com
Legal Status:
Guardian is:
Guardian Name:

First NameLast Name
Guardian Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Email Address:
example@example.com
POA Name:

First NameLast Name
POA Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
POA Email
example@example.com
Health Care Representative Name:

First NameLast Name
Health Care Representative Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Health Care Representative Email:
example@example.com
Guardian/ POA/ HCR Involvement:
Funding
Insurance:

Other
Medicaid Number:
Medicare Number:
Funding:

Other
Waiver Case Manager:
Waiver Case Manager Phone Number:
Waiver Case Manager Email:
example@example.com
About You:
Activities you enjoy: (Select All that Apply)

Other
Likes/ Enjoy Doing/ What makes you happy: (If checked above, you do not need to list)
Strengths: (What are you good at)
Emotional Wellbeing- (mental health concerns, are you generally happy, what kind of encouragement do you need, what lifts your mood, etc.)
What are your hopes for the future:
What is your vision of a good life?
What works well?
What does not work well/ barriers to your success?
Please list any words, activities, subjects to avoid talking about or doing, any fears (dogs, cats, highways)
Primary Language:

Other
Communication: (Select all that apply)

Other
Learning Style (Select all that apply)

Other
Communication, corresponding, learning methods comments:
Reading & Writing Skills (Check any that apply)

Other
Do you currently use any of the following technology:

Other
Assistive Technology Details:
Staff Preference:
Environmental Preferences: Select All that apply

Other
Additional Supports: Select All that apply

Other
Daily Life

What a person does as part of everyday life, school, employment, volunteering, communication, routines, and life skills.
What is your typical daily routine?
Living Situation:
Number in household:
Current Residential Provider:
Services Received by other organizations:

Other
Education- Highest Level of School Completed:
Name of High School/ Location
Graduation Date (Month/ Year)
Name of College/ Trade School/ Location
Dates Attended From/ To:
Did you Graduate?
Degree/ Course of Study:
Employment

What a person does as part of everyday life, school, employment, volunteering, communication, routines, and life skills.
Employment: (Select all that apply)

Other
Dream Job:
What type of jobs would you NOT like?
Work Restrictions/ Accommodations/ Adaptive Equipment:
Prior Work History:
Current Employment Information:
Job Title:
Employer:
Work Schedule (Location/ transportation/ meals)
Work Transportation:
Job Duties:
Job Start Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of work:
Job Pay Rate:
Hours scheduled per week:
Supervisor:
Workplace Address:
Workplace Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Describe Prior work history (Title/ responsibilities/ locations/ time frame)
Work Notes:
Community Living

Where and how someone lives, housing and living options, community access, transportation, home adaptation and modification.
Modes of Transportation:

Other
Transportation Support:
Requires 24/7 Support?
Alone Time Notes:
What do you like to do when you are at home?
Select the items you need support with:

Other
Cooking/ Meal Planning & Prep Support Needed:
Finance support Needed: (banking/ spending money)
Grocery Shopping Support Needed:
Household management/ chores & support needed:
Household Supply shopping Support Needed:
Laundry Support needed:
Mail Support Needed:
Phone support Needed:
Are there pets in the home?
Any history of biting or aggressive behavior?
List Pets:
Are there firearms/ weapons in the home?
Are they locked up?
Do you receive any of the following?

Other
SSI Amount:
SSDI Amount:
Food Stamp Amount:
TANF Amount:
Public Housing Program or Complex:
Safety and Security

Staying safe and secure – finances, emergencies, wellbeing, decision making supports, legal rights and issues
Who do you go to if you need help or you need to talk?
Do you have a criminal history?
Criminal history Details:
Emergency Evacuation Support Needed: (Tornado, Fire, Earthquake, Bomb Threat, Gas leak)

Other
Emergency Evacuation Needs:
Community Safety Abilities/ Support: (Select all that apply)

Other
Support needs in the community?
Elopement Concerns (Select all that apply)

Other
Elopement Risk Notes:
Medical Diagnosis and Medications:
Primary Diagnosis:
Secondary Diagnosis:
If no Secondary Diagnosis enter NA
Do you have additional Diagnosis's to add:
Additional Medical Diagnosis:
Examples include Diabetes, Hypothyroid, High blood pressure, High cholesterol, Obesity or enter NA
Who supports you in making health and medical decisions?
Preferred Hospital Name and Location:
Medications: (Select All that Apply)

Other
Medications VR: (Select All that Apply)

Other
Medication administration: (Select all that apply)

Other
Would you like to enter your medications manually or upload a list (Physician orders or a list that includes medication, dose, route, time)
Medication Administration notes:
Upload Medication List or enter medications below:

Cancelof

Current Pharmacy: (Name, address, phone number)
I authorize the staff at Noble to administer prescribed medications in accordance with written orders of the prescribing physician(s). I understand that if I have questions at any time about medications that I can ask Noble staff, I can contact a Noble nurse, or I will be assisted in asking the prescribing physician any questions that I may have.
Medical Appointment support needed:
Medical Contacts:
Do you have the following:

Other
Community Living Additional Medical Contacts:

Other
Primary Care Physician Name:
Primary Care Physician Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Psychiatrist Name:
Psychiatrist Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Behavior Clinician Name:

First NameLast Name
Behavior Clinician Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Behavior Clinician Email:
example@example.com
Please check any items that the individual has a current or history of:

Other
Do you have a Behavior Support Plan in place?

Other
Target Behaviors: (If not noted above)
Proactive Strategies:
Healthy Living

Managing and accessing health care and staying well – medical, mental health, behavior, developmental, wellness and nutrition.
Overall General Health;
Dining: (Select All that Apply)

Other
Dining: (Select All that Apply) VR

Other
Food preparation/ Meal Supervision/ Dining Skills notes:
Food texture/ Fluid notes:
Dietary restrictions/ supplements notes:
Positioning Needs/ Gtube/Jtube notes:
Vision issues?
Vision concerns (Select all that apply)

Other
Vision notes:
Hearing issues?
Hearing Concerns (Select all that apply)

Other
Hearing notes:
Mobility needs / Adaptive Equipment needed?
Mobility / Adaptive Equipment (Select all that apply)

Other
Mobility/ Adaptive Equipment notes:
Toilet Support Required:
Toileting support needed:

Other
Toileting Support Notes:
Genitourinary:

Other
Requires hygiene & grooming support: (hair, shaving, deodorant, teeth, showers)
Type of support hygiene & grooming support needed:

Other
Hygiene & Grooming Notes: (Needs support with...)
Diabetes diagnosis?
Diabetes:
Blood Sugar Notes: (What to do if blood sugar is low/ Who should be contacted/ Diet Restrictions)
Insulin Notes:
Neurological:

Other
Respiratory:

Other
Skin:

Other
Seizure diagnosis?
Seizures:
Type of Seizures?

Other
Typical seizure activity: (Triggers, Aura, what is typical after a seizure)
How long do they typically last?
How often do they occur?
Vagas Nerve Simulator: (Where do you keep your magnet, what are the instructions for your magnet?)
Do you have allergies?
Allergies: (Select All that apply)

Other
Where is the EpiPen stored?
What are your allergies?
Do you have constipation?
Constipation:
Dehydration Issues?
Dehydration: (Select All that Apply)

Other
Dental Health is good:
Dental Concerns:

Other
Other:

Other
Social & Spiritual

Building friendships and relationships, leisure activities, personal networks and faith community.
Family, Friends & Relationships, Natural Supports: (Who is important to you and how often do you see them)
Cultural Preferences: (Beliefs, religious involvement)
Advocacy & Citizenship

Building valued roles, making choices, setting goals, assuming responsibility and driving how one’s own life is lived.
Self Determination/rights – Level of Understanding (i.e. self awareness, problem solving, decision making, goal setting and communication of wants and needs)
Level of Consumer input in PCISP Development/ Team Meetings:

Other
Are you interested in Self Advocacy?

Other
Registered Voter?
Demographic Information

The following questions regarding Gender, Race, Ethnicity and Household status are OPTIONAL.
Gender:

Other
Race:
Ethnicity:
Number in Household:
Household Earnings for 1:
Household Earnings for 2:
Household Earnings for 3:
Household Earnings for 4:
Household Earnings for 5:
Household Earnings for 6:
Household Earnings for 7:
Household Earnings for 8:
Household Earnings for 9:
Household Earnings for 10:
Household Earnings for 11:
Household Earnings for 12:
Household Earnings for 13:
Household Earnings for 14:
Person Completing this form:

First NameLast Name
Title:
Email Address: You will receive a copy of the completed packet along with additional intake instructions.
example@example.com
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is Mother Guardian?
Is Father Guardian?
Community Living Financial Support
Community Living Financial Involvement (Select all that apply)

TAXES- choose to have Noble file and submit in a timely manner any and all state and federal tax forms that may need to be submitted on my/my ward’s behalf. I understand that it is my responsibility to make sure that Noble has all the appropriate information (ie W2’s, 1099’s) in a timely manner in order to complete the forms correctly and in a timely fashion. Originals will be kept on file in Noble’s Administration Office.SOCIAL SECURITY (SSI/ SSDIFUNDS)- I choose to have Noble handle all affairs with the local Social Security Office on my/my ward’s behalf. This includes filing all necessary paperwork for initial applications and renewals in a timely manner. This also includes Noble becoming the Representative Payee with Social Security and setting up the appropriate Representative Payee checking account with Noble’s bank of choice. I understand that I/my ward will have no access to this account and that all checks and statements will go to, and be held by, Noble. I understand that Noble will be responsible for making sure all monthly expenses for basic needs (ie rent, utilities, food, medical expenses) are paid, and that if my/my ward’s personal budget allows, I/they will be given a weekly allotment for personal spending. Noble will send reports by the 15th of each month listing all income and expenses for the previous month.

Financial Ability Status:

Rows	Yes	No	NA	Comments
Able to independently manage all finances
Requires full support with all financial transactions and oversight
Is able to independently manage cash
Can count money
Understands financial transactions
At risk for financial exploitation

Psychologist Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Psychologist Name:
Medical Specialist Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Medical Specialist Name:
Adult Day Services (ADS)

Adult Day Services encompasses the health and social needs of an indivdiual. Individuals who select ADS typically have greater medical and health needs than someone who may select Day Habilitaiton Group.

In order to receive ADS services an indivdual must receive an assessment (Adult Day Service Level of Service Evaluation Form, completed by the Waiver Case Manager) to determine the Level of Service needed.

Noble Provides ADS at its Noble East location at 7701 E 21st Street, Indianapolis, IN 46219. ADS is seperate from the Day Habilitation Program.

Day Habilitation Group Services: (DHG)

Day Habilitation Group Services support learning and assistance in the areas of: self-care, sensory/motor development, socialization, daily living skills, communication, community living and social skills. Day Habilitation activities are intended to build relationships and natural supports.
- Noble provides DHG services in a variety of settings and locations:
  - East: 7701 E 21st Street, Indianapolis, In
  - Campus- Noblesville: 216 Lakeview Drive, Noblesville, In
  - Campus- Mary Rigg Community Center
  - Campus: Garfield Park
  - Career Exploration Group: 50 S. Shelby, Indianapolis, In - Focus is on exploring, preparing and obtaining employment.
  - Noble Art: 5011 W 16th Street, Speedway, IN 46224
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Noble Intake Application

Personal Information

Contacts

Funding

About You:

Daily Life

Employment

Current Employment Information:

Community Living

Safety and Security

Medical Diagnosis and Medications:

Medical Contacts:

Healthy Living

Social & Spiritual

Advocacy & Citizenship

Demographic Information

Community Living Financial Support