Noble Intake Application

Noble Intake Application

2025
Date of intake:

MonthDayYear
Date
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 Tony Palmer, Noble Intake Coordinator at t.palmer@mynoblelife.org or at 317-375-4228.

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.
- EQUITY: 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.
- DIVERSITY: We believe that society in general, and Noble in particular, benefit from the contributions of people with diverse personal characteristics, including but not limited to race, ethnicity, religion, age, national origin, sexual orientation, gender, disability, marital status and veteran status.
Charting the LifeCourse:
- Foundation
- Infographic
Primary Service Requested:*

Behavior TherapyCareer Exploration Group (Career Center)Career Exploration & PlanningCommunity Living (Residential)Day Habilitation- CampusDay Habilitation- IndividualDay Habilitation Group- EastDay Habilitation- TibbsExtended Services/ SEFA- IndyExtended Services/ SEFA- RichmondMusic TherapyPAC- Personal Assistance CareRecreational TherapyRespiteVocational Rehabilitation (VR)- IndyVocational Rehabilitation (VR)- RichmondADS- Adult Day ServiceOther
Are you interested in other Noble services?*

YesNo
Additional Services you are interested in: (Select all that apply)*

Behavior TherapyCareer Exploration Group (CEG)Career Exploration & PlanningExtended Services/ SEFA- IndyExtended Services/ SEFA- RichmondCommunity Living (Residential)Day Habilitation- CampusDay Habilitation- IndividualDay Habilitation Group- EastDay Habilitation- TibbsCareer Exploration Group- Career CenterMusic TherapyPAC- Personal Assistance CareRecreational TherapyRespiteADS- Adult Day ServiceOther
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
- Tibbs: 2406 N Tibbs Ave, Indianapolis, In (West Side)
- Campus- Noblesville: 216 Lakeview Drive, Noblesville, In
- Campus- Mary Rigg:
- Career Exploration Group: 50 S. Shelby, Indianapolis, In - Focus is on exploring, preparing and obtaining employment.
What days and times do you prefer to receive services: *
Personal Information
Full Name: *

First NameLast Name
Nickname:
Date of Birth: *

MonthDayYear
Date
Individuals Cell Phone Number:
Please enter a valid phone number.
Individuals Home Phone Number: *
Please enter a valid phone number.
Individuals Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:*

BooneHamiltonHancockHendricksJohnsonMarionMorganOther
Email Address:
example@example.com
Marital Status:*

SingleMarriedOther
Spouse Name:

First NameLast Name
Spouse Cell Phone:
Please enter a valid phone number.
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?*

YesNo
Social Security Number: (Employment)
If you decline enter
Do you have a current Driver's License or State ID card? (Employment/ Residential)*

YesNo
DL/State ID- Expiration Date: *
Contacts
Contact(s): (Select All that Apply)*

MotherFatherResidential ProviderOther
Is Mother's address the same as the Individual?*

YesNo
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.
Mother Home Phone:
Please enter a valid phone number.
Mother Email: *
example@example.com
Is Father's address the same as the Individual?*

YesNo
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.
Father Home Phone:
Please enter a valid phone number.
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.
Primary Emergency Contact Home Phone Number:
Please enter a valid phone number.
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.
Residential Provider Home Phone Number:
Please enter a valid phone number.
Residential Provider Email:*
example@example.com
Legal Status: *

EmancipatedHas GuardianHas Power of Attorney (POA)Has a Health Care RepresentativeMinor (Under 18 years old)
Guardian is:*

MotherFatherPrimary ContactOther
Guardian Name: *

First NameLast Name
Guardian Phone Number: *
Please enter a valid phone number.
Guardian Email Address:
example@example.com
POA Name: *

First NameLast Name
POA Phone Number*
Please enter a valid phone number.
POA Email
example@example.com
Health Care Representative Name: *

First NameLast Name
Health Care Representative Phone Number:*
Please enter a valid phone number.
Health Care Representative Email:
example@example.com
Guardian/ POA/ HCR Involvement:*
Funding
Insurance:*

MedicaidMedicarePrivateOther
Medicaid Number: *
Medicare Number:
Funding:*

No waiver- Do not plan to applyFamily Support (FSW)Community Habilitation Waiver (CIH)Aged and Disabled (A&D)Pathways for Aging WaiverHealth and Wellness WaiverOBRATXXPrivate PayVocational RehabilitationApplied for a WaiverOther
Waiver Case Manager: *
Waiver Case Manager Phone Number:
Waiver Case Manager Email:
example@example.com
About You:
Activities you enjoy: (Select All that Apply)*

ArcadesArts/ CraftsBeing out and aboutBoard GamesBowlingCard GamesCleaningConcertsCookingDrawing/ ColoringDriving in a carFishingGoing out to eatGoing to sports gamesHaving people overHikingLibrariesListening to musicMoviesParksReadingRiding BikesSensory itemsShoppingSpecial OlympicsSwimmingTablet/ ComputerTVVacationsVideo GamesWalkingWatching SportsOther
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:*

EnglishSpanishOther
Communication: (Select all that apply)*

Allow time to processCan communicate wants and needsCommunication DeviceConcreteDirectHas a history of speech therapyUses an iPad/ tabletIs able to make choices about ones daily lifeIs Easily UnderstoodIt is helpful to have questions repeatedNon VerbalOtherPrompts are needed to encourage communication or processingSigns/ GesturesSimpleStep by stepVerbalVisual Cue CardsVisual PromptsOther
Learning Style (Select all that apply)*

Allow time to processConcreteDemonstration with verbal instructionDirectHand over HandOne step at a timeRepetitionSimpleStep by stepVerbalVisualOther
Communication, corresponding, learning methods comments:
Reading & Writing Skills (Check any that apply)*

Can read proficientlyCan read someCan write name onlyCan write proficientlyCan write someCannot readCannot writeOther
Do you currently use any of the following technology:*

NoneAutomated Medication DispserCell PhoneCommunication DeviceComputerEchoHeadphonesiPadKindelMusic Player (Walkman/ iPod, etc.)No Technology Used at this time but am interested in learning moreRemote Supports (In home video/audio support, life alert, etc)TabletOther
Assistive Technology Details:
Staff Preference:*

No PreferenceFemaleMale
Environmental Preferences: Select All that apply*

No PreferencePrefer being with peoplePrefer to be alonePrefers to be at homePrefer to work alonePrefers quite environmentsPrefers to be indoorsPrefers to be outdoorsPrefers to only be around people they knowOther
Additional Supports: Select All that apply*

NoneDoes best with a visual scheduleExperiences behavior/ emotional meltdownsNeeds extra processing timeNeeds social cue promptingTransition GuidanceUnable to associate consequences with actionsUse of first/ then statementsOther
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:*

Live aloneLive in own home with roommatesGroup HomeLive with FamilyStructured Family Caregiving
Current Residential Provider:
Services Received by other organizations:*

NoneAdult Day ServicesCareer Exploration and PlanningDay Habilitation Group (DHG)Day Habilitation Individual (DHI)Extended ServicesHome Health (PA)Music TherapyPersonal Assistance and Care (PAC)Personal Emergency Response SystemPrevocational ServicesRecreational TherapyRemote SupportsResidential HabilitationRespiteOther
Education- Highest Level of School Completed:*

Less than high schoolSome high schoolHigh School- GED/ DiplomaHigh School CertificateSome CollegeTwo- Year degreeTechnical Degree/ CertificationFour Year DegreeMasters DegreeDoctorate DegreeUnknown
Name of High School/ Location
Graduation Date (Month/ Year)
Name of College/ Trade School/ Location
Dates Attended From/ To:
Did you Graduate?

YesNo
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)*

Employed Full time (more than 35 hours per week)Employed Part-time (Less than 35 hours a week)Unemployed but would like a jobUnemployed- Not interested in EmploymentRetiredStudentHomemakerHas or will have work restrictions (lifting, standing, etc.)Has or will need adaptive equipmentHas or will need work accommodationsHas prior work historyInterested in volunteeringEnrolled in Vocational Rehabilitation (VR)Working with a Job CoachOther
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
Date
Type of work:
Job Pay Rate:
Hours scheduled per week:
Supervisor:
Workplace Address:
Workplace Phone #:
Please enter a valid phone number.
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:*

City BusDrivesFamily transportLyft/ UberOpen DoorRides BicycleStaff transportOther
Transportation Support:
Requires 24/7 Support?*

YesNo
Alone Time Notes: *
What do you like to do when you are at home? *
Select the items you need support with:*

NoneMeal Planning/ Meal Prep and CookingGrocery ShoppingFinancial supportHousehold Management/ ChoresHousehold Supply shoppingLaundryMail SupportPhone SupportOther
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?*

YesNo
Any history of biting or aggressive behavior?*

YesNo
List Pets:
Are there firearms/ weapons in the home?*

YesNo
Are they locked up?*

YesNo
Do you receive any of the following? *

SSISSDIFood Stamps (SNAP)TANFPublic Housing AssistanceOther
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?*

YesNo
Criminal history Details:*
Emergency Evacuation Support Needed: (Tornado, Fire, Earthquake, Bomb Threat, Gas leak)*

None: Able to independently evacuate in an emergency (no verbal or physical prompts)Physical Assistance neededVerbal Prompts neededTotal assistance requiredOther
Emergency Evacuation Needs:
Community Safety Abilities/ Support: (Select all that apply)*

Independent in all areas while in the communityAble to Access Emergency ResponseAble to Demonstrate Community SafetyAble to Give Identification InformationCommunity Safety Risk Plan is in placeDoes not have pedestrian safety awarenessElopement RiskMust be monitored in parking lotsMust be monitored at ALL times in the communityNeeds assistance with money management while in the communitySusceptible to abuse/ exploitationUnable to defend self against sexual or physical abuseUnable to give identificationUnable to report abuse to appropriate personUnable to respond to emergenciesUnderstands stranger awarenessWanders in Familiar Settings.Wanders in Unfamiliar SettingsWanders while in the CommunityOther
Support needs in the community? *
Elopement Concerns (Select all that apply)*

Wandering in Familiar Settings.Wandering in Unfamiliar SettingsWandering While in the CommunityLeaving Home Without SupervisionLeaving Noble Without SupervisionLeaving the Program Without SupervisionLeaving the Premises When AngryOther
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:*

YesNo
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)*

Does not take medicationTakes Medication on a daily basisTakes medication to help manage emotionsWill take medications while at NobleAble to independently make health and medical decisions for day to day wellbeingRequires support to make health and medical decisions for day to day wellbeingIndependent in Medication AdministrationIndividual understands why they are taking medicationsRequires support at Medical AppointmentsOther
Medications VR: (Select All that Apply)*

Takes Medication on a daily basisDoes not take Medications on a daily basisOther
Medication administration: (Select all that apply)*

CrushedEnteralIn puddingIn applesauceOrallyWholeOther
Would you like to enter your medications manually or upload a list (Physician orders or a list that includes medication, dose, route, time)

Enter ManuallyUpload listWill submit the medication list prior to services starting.
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.*

YesNo
Medical Appointment support needed: *
Medical Contacts:
Do you have the following:*

Not ApplicableBehavior ClinicianPrimary Care PhysicianPsychiatrist (Behavior Services Only)Other
Community Living Additional Medical Contacts:*

Medical SpecialistPsychologistOther
Primary Care Physician Name: *
Primary Care Physician Phone Number:
Please enter a valid phone number.
Medical Specialist Name: *
Medical Specialist Phone Number:
Please enter a valid phone number.
Psychiatrist Name: *
Psychiatrist Phone Number:
Please enter a valid phone number.
Psychologist Name: *
Psychologist Phone Number:
Please enter a valid phone number.
Behavior Clinician Name: *

First NameLast Name
Behavior Clinician Phone Number:
Please enter a valid phone number.
Behavior Clinician Email:*
example@example.com
Do you have a Behavior Support Plan in place?*

YesNoOther
Behaviors:*

NoneAttention- Seeking BehaviorDisruptive BehaviorsElopementInappropriate Social InteractionsNon- ComplianceNon- ComplianceNonePhysical AggressionProperty DestructionSelf- InjuriousSelf-Stimulatory BehaviorStealingSuicidal or homicidal gestures or threatsTask AvoidanceUnsafe Sexual BehaviorVerbal AggressionOther
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;*

ExcellentGoodFairPoor
Dining: (Select All that Apply)*

Choking RiskChoking or Dining High Risk Plan in placeAt risk for aspiration/ history of aspirationAdaptive dining equipment in place (utensils, bowl, straws, cups)Diagnosed with GERDPositioning needs during or after eatingDietary Restrictions in place (gluten-free, dairy free, vegan, diabetic diet)Dietary Supplements in place (ensure, etc.)Dining skills to maintain or acquire (eat slow, take small bites)Food Texture Accommodations in place (pureed, minced, moist, soft & tender)Fluid Texture Accommodations in place (slightly thick, nectar thick, honey)History of PneumoniaG-Tube/ J-Tube- Receives Medication, nutrition, or hydration enterallyRequires supervision while eatingSpecific Nutrition NeedsRequires supervision while eatingRequires assistance with physically eatingSupport needed when preparing foodVerbal prompts needed while eatingOther
Dining: (Select All that Apply) VR*

Choking RiskDietary RestrictionsOther
Food preparation/ Meal Supervision/ Dining Skills notes: *
Food texture/ Fluid notes: *
Dietary restrictions/ supplements notes: *
Positioning Needs/ Gtube/Jtube notes: *
Vision issues?*

YesNo
Vision concerns (Select all that apply)*

Vision Risk plan in placeBlindBlind in right eyeBlind in left eyeNearsightedCataractsFarsightedGlaucomaWears GlassesMacular DegenerationUnspecified visual impairmentNA- No Vision ConcernsOther
Vision notes:
Hearing issues?*

YesNo
Hearing Concerns (Select all that apply)*

Hearing Risk Plan in placeComplete hearing lossLeft ear hearing lossRight ear hearing lossUses hearing aids/ deviceNA- No Hearing ConcernsOther
Hearing notes:
Mobility needs / Adaptive Equipment needed?*

Ambulatory with no issuesYesNo
Mobility / Adaptive Equipment (Select all that apply)*

Fall RiskFall/ Mobility Risk Plan in placeDependent on staff for lifts & transfersHas experienced one or more falls in the past 12 months?Has experienced one or more fractures in the past 3 years?History of frequent fallsMobility /Fall Risk plan in placeOther adaptive equipmentRequires a Hoyer lift for transfersRequires an accessible vehicleRequires repositioningUnsteady gaitUses adaptive dining equipmentUses a caneUses a gait beltUses a walkerUses a wheelchairUses bracesUses crutchesWears a helmetNA- No Mobility IssueOther
Mobility/ Adaptive Equipment notes:
Toilet Support Required:*

YesNo
Toileting support needed:*

Assistance after a bowel movementAssistance with clothingAssistance with hand washingAssistance with transfersAssistance with wipingIncontinent of bladderIncontinent of bowelNeeds remindersRequires 2-person supportRequires a Hoyer LiftUses depends/ adult diaperNA- No Toileting Support NeededOther
Toileting Support Notes:
Genitourinary:*

No issuesHistory of Urinary Tract infectionsHistory of kidney stonesIssues with retentionDribblingOther
Requires hygiene & grooming support: (hair, shaving, deodorant, teeth, showers)*

YesNo
Type of support hygiene & grooming support needed:*

Needs reminders/ verbal promptsNeeds hand over hand supportNeeds physical assistanceNA- No Support NeededOther
Hygiene & Grooming Notes: (Needs support with...)*
Diabetes diagnosis?*

YesNo
Diabetes:*

Diabetes Risk Plan in placeTakes InsulinTakes Medication for DiabetesChecks Blood SugarIndependent in Checking blood sugarDiet Restrictions in place due to diabetesFor high/low blood sugar Noble will need to notify someone
Blood Sugar Notes: (What to do if blood sugar is low/ Who should be contacted/ Diet Restrictions)*
Neurological:*

No issuesSeizuresSymptoms of Alzheimer's or DementiaHydrocephaly and/or Cerebral ShuntOther
Respiratory:*

No issuesDiagnosis of asthmaDiagnosis of emphysemaDiagnosis of Chronis Obstructive Pulmonary Disease (COPD)Diagnosis of Sleep ApneaOther
Skin:*

No issuesDiabetes MellitusEczemaHistory of pressure sores/ skin ulcer the last 12 monthsPeripheral Vascular DiseasePsoriasisOther
Seizure diagnosis?*

YesNo
Seizures:*

History of SeizuresSeizure High Risk Plan in placeAurora PresentTriggers for seizuresUses a Vagus Nerve SimulatorTakes Medication for seizures
Type of Seizures?*

Absence (petit mal)Tonic-Clonic (grand mal)MyoclonicAtonicClonicTonicOther
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?*

YesNo
Allergies: (Select All that apply)*

Allergy Risk Plan in placeFood AllergiesEnvironmental AllergiesInsect AllergyMedication AllergyHas an EpiPen in placeHas life threatening allergySeasonal AllergiesOther
Where is the EpiPen stored? *
What are your allergies? *
Do you have constipation?*

YesNo
Constipation:*

High Risk Plan in placeDiagnosis of Chronic ConsitpationDiagnosis of Recurrent ConstipationRequires routine medication for constipationRequires As needed (PRN) Medication for constipationRequires Fiber Supplements for RegularityHas a History of Bowel Obstruction
Dehydration Issues?*

YesNo
Dehydration: (Select All that Apply)*

Dehydration Risk Plan in placeFrequent Refusals of FluidsHistory of Recurrent dehydrationNeeds prompts to Drink adequate FluidsTakes Medication that may cause dehydrationOther
Dental Health is good:*

YesNo
Dental Concerns:*

DenturesDiagnosed with periodontal diseaseMissing several teethNo teethHas broken teethPoor dental hygieneOther
Other:*

NoneSmokes Cigarettes/ Cigars or VapesDrinks AlcoholUses Recreational DrugsAt risk for using/ingesting household chemicals/potentially toxic items inappropriatelyDiagnosis or behaviors of PICA (ingesting non-nutritive substances)Needs assistance to use household appliances safelyNeeds assistance to adjust water temperatureNeeds assistance to dress appropriately for weather conditionsNeeds assistance to open locked doorsUnable to give identification information if neededUnable to access emergency response independentlyLacks water safety skillsInability to defend self against physical abuseInability to report physical abuse to appropriate personHypothyroidism diagnosisHypertension diagnosis (High blood pressure)Hypothyroidism diagnosis (Low blood pressure)High CholesterolPrader- Willi SyndromePICAOther
Social & Spritual

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:*

Independently expresses their preferences and needsRequires prompts to express their preferences and needsRelies on their team members or family to express their preferences and needsOther
Are you interested in Self Advocacy?*

Not InterestedNoble Self Advocates GroupSelf Advocates of Indiana Group MeetingsOther
Registered Voter?*

YesNo
Community Living Financial Support
Community Living Financial Involvement (Select all that apply)*

NO INVOLVMENT- I choose not to have Noble involved in taking care of my taxes, Food Stamps (SNAP EBT), Medicaid, or Social Security. All paperwork and tracking will be handled by me or another chosen representative.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.FOOD STAMPS (SNAP/EBT)- choose to have Noble handle all affairs with the local Food Stamp Office on my/my ward’s behalf. This includes filing all necessary documentation for initial applications, status change and updates, annual renewals as scheduled, and tracking the use of my monthly allotments. The EBT card will be kept in the home.MEDICAID/ MEDICARE- I choose to have Noble handle all affairs with the local Medicaid/Medicare office on my/my ward’s behalf. This includes filing all necessary documentation for initial applications, renewals as scheduled, and making sure all medical providers have the correct information on file for reimbursement purposes. The identification card will be kept in the home.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.FULL INVOLVMENT- I choose to have Noble take care of all the above responsibilities on my/my behalf.

Demographic Information

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

MaleFemaleTransgender Male (gender not aligned with the sex assigned at birth)Transgender Female (gender not aligned with the sex assigned at birth)Non-BinaryUnknownDeclineOther
Race:

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderSome other RaceTwo or More RacesWhiteUnknownDecline
Ethnicity:

Hispanic or LatinoNot Hispanic or LatinoUnknownDecline
Number in Household:
Household Earnings for 1:

Under $ 15,060.00Between 15,061.00 and 27,861.00At or Above 27862UnknownDecline
Household Earnings for 2:

Under $ 20,440.00Between 20,441.00 and 37,814.00At or Above 37815UnknownDecline
Household Earnings for 3:

Under $ 25,820.00Between $25,821.00 and $47,767.00At or Above $47,768.00UnknownDecline
Household Earnings for 4:

Under $ 31,200.00Between $31,201.00 and $57,720.00At or Above $57,721.00UnknownDecline
Household Earnings for 5:

Under $ 36,580.00Between $36,581.00 and $67,673.00At or Above $67,674.00UnknownDecline
Household Earnings for 6:

Under $ 41,960.00Between $41,961.00 and $77,626.00At or Above $77,627.00UnknownDecline
Household Earnings for 7:

Under $ 47,340.00Between $47,341.00 and $87,579.00At or Above $87,580.00UnknownDecline
Household Earnings for 8:

Under $ 52,720.00Between $52,721.00 and $97,532.00At or Above $97,533.00UnknownDecline
Household Earnings for 9:

Under $ 58,100.00Between $58,101.00 and $107,485.00At or Above $107,486.00UnknownDecline
Household Earnings for 10:

Under $ 63,480.00Between $63,481.00 and $117,438.00At or Above $117,439.00UnknownDecline
Household Earnings for 11:

Under $ 63,480.00Between $63,481.00 and $117,438.00At or Above $117,439.00UnknownDecline
Household Earnings for 12:

Under $ 74,240.00Between $74,241.00 and $137,344.00At or Above $137,345.00UnknownDecline
Household Earnings for 13:

Under $ 79,620.00Between $79,621.00 and $147,297.00At or Above $147,298.00UnknownDecline
Household Earnings for 14:

Under $ 85,000.00Between $85,001.00 and $157,250.00At or Above $157,251.00UnknownDecline
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*

Clear
Date

MonthDayYear
Date
Is Mother Guardian?*

YesNo
Is Father Guardian?

YesNo
Should be Empty:

	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

	Medication	Frequency	Purpose	Dose
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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 & Spritual

Advocacy & Citizenship

Community Living Financial Support

Demographic Information