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Noble Intake Application
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 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.
Referral Date:
-
Month
-
Day
Year
Date
Noble Services: (Select all that apply)
*
ADS- Adult Day Service
Behavior Therapy
CDE
Community Employment- Indy
Community Employment- Richmond
Community Living
Day Habilitation- Campus
Day Habilitation- Individual
Day Habilitation Group- East
Day Habilitation- Tibbs
Career Exploration Group- Career Center
Music Therapy
PAC- Personal Assistance Care
Recreational Therapy
Respite
Vocational Rehabilitation (VR)
Other
Legal Status:
*
Emancipated
Has Guardian
Has Power of Attorney (POA)
Has a Health Care Representative
Full Name:
*
First Name
Last Name
Nickname:
HIPAA Name:
*
First four letters of the last name and the first three letters of the first name. James Smith= SmitJam
Date of Birth:
*
-
Month
-
Day
Year
Date
Guardian Name:
*
First Name
Last Name
Guardian Phone Number:
*
Please enter a valid phone number.
Guardian Email Address:
example@example.com
POA Name:
*
First Name
Last Name
POA Phone Number
*
Please enter a valid phone number.
POA Email
example@example.com
Health Care Representative Name:
*
First Name
Last Name
Health Care Representative Phone Number:
*
Please enter a valid phone number.
Health Care Representative Email:
example@example.com
Who is present for this intake: (Name, title/ relationship)
*
Date of intake:
*
-
Month
-
Day
Year
Date
Personal Information/ Demographics
Individuals Phone Number:
*
Please enter a valid phone number.
Individuals Cell Phone Number:
Please enter a valid phone number.
Individuals Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Last 4 digits of the Individuals Social Security Number:
*
Social Security Number:
*
DL/ State ID information current?
*
Yes
No
Drivers License/ State ID #:
*
Expiration Date:
*
Upload a copy of the Drivers License/ State ID:
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Eye Color:
*
Blue
Brown
Gray
Green
Black
Hazel
Hair Color:
Bald
Black
Blonde
Brown
Gray
Red
White
Height:
*
Weight:
*
Gender:
*
• Male
• Female
• Transgender Male (gender not aligned with the sex assigned at birth)
• Transgender Female (gender not aligned with the sex assigned at birth)
• Non-Binary
• Unknown
Race:
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Some other Race
Two or More Races
White
Unknown
Ethnicity:
*
Declined
Hispanic or Latino
Not Hispanic or Latino
Unknown
County:
*
Boone
Hamilton
Hancock
Hendricks
Johnson
Marion
Morgan
Other
Gross Annual Income (earnings before taxes)
*
Enter 0 if you DECLINE
Number in household:
*
Enter 0 if you DECLINE
Marital Status:
*
Single
Married
Other
Medicaid Number:
*
Medicare Number or enter N/A:
Other Health Insurance:
Language:
Medicaid Waiver:
*
Family Support (FSW)
Community Habilitation Waiver (CIH)
Aged adn Disabled (A&D)
OBRA
TXX
No Waiver- Do not plan to apply
No Waiver- Plan to apply
Private Pay
Vocational Rehabilitation
Applied for a Waiver
Other
Waiver Case Manager:
*
Waiver Case Manager Phone Number:
*
Waiver Case Manager Email:
*
example@example.com
Mother:
*
Living
Deceased
No Conact
Unknown
Is Mother also Guardian or Primary Contact:
*
Yes
No
Mother Name:
*
First Name
Last Name
Mother Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mother Home Phone:
*
Please enter a valid phone number.
Mother Cell Phone:
Please enter a valid phone number.
Mother Email:
example@example.com
Father:
*
Living
Deceased
No Conact
Unknown
Is Father Guardian or Primary Contact:
*
Yes
No
Father Name:
*
First Name
Last Name
Father Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Father Home Phone:
*
Please enter a valid phone number.
Father Cell Phone:
Please enter a valid phone number.
Father Email:
example@example.com
Primary Contact:
*
Mother
Father
Other
Primary Emergency Contact:
*
First Name
Last Name
Primary Emergency Contact Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Emergency Contact Home Phone Number:
Please enter a valid phone number.
Primary Emergency Contact Cell Phone Number:
*
Please enter a valid phone number.
Primary Emergency Contact Email
example@example.com
Do you have an additional Emergency Contact to add?
*
Yes
No
Additional Emergency Contact:
*
First Name
Last Name
Additional Emergency Contact Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Emergency Contact Home Phone Number:
Please enter a valid phone number.
Additional Emergency Contact Cell Phone Number:
*
Please enter a valid phone number.
Additional Emergency Contact Email:
example@example.com
Behavior Information
Do you have the following:
*
Behavior Clinician
Primary Care Physician
Medical Specialist
Psychiatrist
Psychologist
Behavior Clinician Name:
*
First Name
Last Name
Behavior Clinician Phone Number:
*
Please enter a valid phone number.
Behavior Clinician Email:
example@example.com
Target Behaviors on the BSP:
*
Frequency of BC Visits:
Medical Information
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.
Primary Diagnosis:
*
Secondary Diagnosis:
*
If no Secondary Diagnosis enter NA
Additional Medical Diagnosis:
*
Examples include Diabetes, Hypothyroid, Highblood pressure, High cholesterol, Obesity or enter NA
Do you take medication on a daily basis?
*
Yes
No
31. Do you take medications to help you manage your emotions?
*
Yes
No
Medications:
*
Medication
Dose
Frequency
Purpose
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Preferred Hospital Name and Location:
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About You:
1. What do people like and admire about you?
*
2. Strengths and Assets (What are you good at)
*
3. What are some things you like or are interested in?
*
4. Emotional Wellbeing- what are some important things for you to have a good day/ life/ healthy relationships, etc.
*
5. What works well when supporting you? What can we do to be proactive in ensuring you have a good day?
*
6. What are you hopes for the future? Vision for a good life?
*
7. What are your goals for service? What do you hope to accomplish & how can Noble support you in meeting your goals?
*
8. What are some barriers to success?
*
9. What does not work well?
*
10. Can you communicate your wants and needs?
*
Yes
No
11. Communication Methods (Select all that apply)
*
Verbal
Non Verbal
Signs/ Gestures
Visual Prompts
Communication Device
Other
12. Communication and corresponding methods comments:
13. Can you make choices about your daily life?
*
Yes
No
14. Skills or prompts needed to encourage communication or processing?
*
Yes
No
15. Easily Understood?
*
Yes
No
16. Communication style that works best. (Select all that apply)
*
Direct
Concrete
Step by step
Simple
Allow time to process
Other
17. Is it helpful to have others repeat questions?
*
Yes
No
18. History of speech therapy?
Yes
No
19. Learning Style
*
20. Reading and Writing skills:
*
21. Assistive Technology / Devices (iPad, cellphone, tablet)
*
22. Goal for technology:
*
23. Staff Preference: (Male, female, no preference)
*
24. Environmental Preference (Prefer to be alone/ work alone/ being with people/ outdoors/ indoors/ quite/ around people you know)
*
25. What do you enjoy doing? What makes you happy?
*
26. Any words, activities, subjects, etc. to avoid talking about or doing?
*
27. Fears: (Dogs, cats, highways)
*
28. How do you express your feelings?
*
29. What coping skills do you use?
*
30. Can you control how you act and feel in social situations, at home?
*
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Daily Life
What a person does as part of everyday life, school, employment, volunteering, communication, routines, and life skills.
1. What is your typical daily routine?
2. Living Situation:
*
Live alone
Live in own home with roommates
Group Home
Live with Family
Structured Family Caregiving
Current Residential Provider:
3. Living situation/ preference notes:
*
4. What do you like to do at Home?
*
5. What do you do in the community? Schedule/ locations/ activities?
*
Do you attend a Day Program?
*
Yes
No
Currently On a Waitlist
6. Day Program Schedule/ location/ meal support/ transportation:
*
7. Family Involvement- Visits, holidays, phone calls, etc.
*
08. What Supports do you have to Help Achieve your Best Life?
*
09. What are your Goals for Services?
*
10. What do you not want?
*
11. Family Vision for a Good Life:
12. Noble Service Information:
13. Services received from other organizations:
*
Or enter NA
Currently in school?
*
Yes
No
14. Completed Adult Education Degree, Certification, or Training:
*
Yes
No
15. Education- Children: Anticipated H.S. Grad Year:
16. Education- Children: Current Grade:
17. Education- Anticipated Graduation Date:
18. Education- Highest Level of School Completed:
*
1. Less than high school
2. Some high school
3. High School- GED/ Diploma
3.5 High School Certificate
4. Some College
5. Two- Year degree
6. Technical Degree/ Certification
7. Four Year Degree
8. Masters Degree
9. Doctorate Degree
9.7 Unknown
19. Education- School Location:
High School Name/ Location:
High School Graduation Date: (Month/Year)
Education Level (check one of the following):
Diploma
Special Education Certificate of Completion
GED
Dropped out of school
Highest Grade Level Completed:
Did you attend College or a Trade School?
Yes
No
College/ Trade School Name/ Location:
Dates attended: FROM
Dates attended: TO
Graduated:
*
Yes
No
Degree:
Course of Study:
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Employment
What a person does as part of everyday life, school, employment, volunteering, communication, routines, and life skills.
1. Employment Status:
*
Employed Full time (more than 35 hours per week)
Employed Part-time (Less than 35 hours a week)
Homemaker
Other
Retired
Student
Unemployed
2. Work Schedule (Location/ transportation/ meals)
3. Would like a job?
*
Yes
No
4. Reason not interested in employment?
*
5. Able to decide if or where they want to work
*
Yes
No
6. Do they have prior work history?
*
Yes
No
7. Describe Prior work history (Title/ responsibilities/ locations/ time frame)
*
8. Dream Job:
9. What type of jobs would you NOT like?
10. Enrolled in VR?
Yes
No
11. Working with a Job Coach?
Yes
No
12. Work Restrictions:
13. Work Accommodations/ Adaptive Equipment:
14. Job Title:
15. Employer:
16. Work Transportation:
17. Job Duties:
18. Job Start Date:
-
Month
-
Day
Year
Date
19. Job End Date:
-
Month
-
Day
Year
Date
20. Type of work:
21. Job Pay Rate:
22. Supervisor:
23. Hours scheduled per week:
24. Work Place Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
25. Workplace Phone #:
Please enter a valid phone number.
26. Date Follow Along Started:
-
Month
-
Day
Year
Date
27. Other pertinent information:
28. Career Counseling Date Completed:
-
Month
-
Day
Year
Date
30. VR Case Open:
31. VR Referral Completed?
Interested in Volunteering?
Yes
No
Volunteer Experience?
Yes
No
Volunteer Details:
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Community Living
Where and how someone lives, housing and living options, community access, transportation, home adaptation and modification.
Modes of Transportation:
*
Drives
City Bus
Family
Open Door
Staff
Lyft/ Uber
Rides Bicycle
Other
1. Transportation Support:
2. Uses Indy Go Access
*
Yes
No
3. Indy Go Access Notes:
*
4. Requires 24/7 Support?
*
Yes
No
5. Alone Time Notes:
6. Emergency Evacuation Support Needed:
*
Yes
No
7. Emergency Evacuation Needs:
*
8. Household management/ chores & support needed:
9. Laundry Support needed:
10. Residential Site Specific Information: (CL Only)
11. Other:
12. Are there pets in the home?
*
Yes
No
13. Any history of biting or aggressive behavior?
*
Yes
No
14. List Pets:
15. Are there firearms/ weapons in the home?
*
Yes
No
16. Are they locked up?
Yes
No
Do you receive any of the following?
*
SSI
SSDI
Food Stamps (SNAP)
TANF
Public Housing Assistance
Other
SSI Amount:
SSDI Amount:
Food Stamp Amount:
TANF Amount:
Public Housing Program or Complex:
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Safety and Security
Staying safe and secure – finances, emergencies, wellbeing, decision making supports, legal rights and issues
1. Who do you go to if you need help or you need to talk?
*
2. Finance support: (banking/ spending money)
3. Emergency Support
4. Criminal history (N/A or Details)
*
5. Support needs in the community?
*
6. Are there any Community Safety Concerns?
*
Yes
No
6. Community Safety Risk Plan in place?
*
Yes
No
08. Community Safety Abilites: (Select all that apply)
*
Able to Give Identification Information
Unable to give identification
Able to Access Emergency Response
Unable to respond to emergencies
Able to Demonstrate Community Safety
Understands stranger awareness
Susceptible to abuse/ exploitation
Needs assistance with money management in the community
Wandering in Familiar Settings.
Wandering in Unfamiliar Settings
Wandering While in the Community
Must be monitored in parking lots
Does not have pedestrian safety awareness
Other
09. Community Money management needs:
*
10. Elopement Risk?
*
Yes
No
12. Elopement Concerns (Select all that apply)
Wandering in Familiar Settings.
Wandering in Unfamiliar Settings
Wandering While in the Community
Leaving Home Without Supervision
Leaving Noble Without Supervision
Leaving the Program Without Supervision
Leaving the Premises When Angry
Other
13. Elopement Risk Notes:
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Healthy Living
Managing and accessing health care and staying well – medical, mental health, behavior, developmental, wellness and nutrition.
1. Is there a choking risk?
*
Yes
No
2. Is there a current risk plan in place?
*
Yes
No
3. Swallowing/ Choking Notes:
4. History of Pneumonia?
*
Yes
No
5. Support needed when preparing food?
*
Yes
No
6. Food preparation needs notes:
7. Verbal prompts needed while eating?
*
Yes
No
8. Requires supervision while eating?
*
Yes
No
9. Meal supervision/ prompts
*
10. Dining Skills to maintain/ acquire?
*
Yes
No
11. Dining Skills to maintain/ acquire notes?
*
12. Dining High Risk Plan in Place?
*
Yes
No
13. Health and Risk Needs:
14. Food or Fluid Texture accommodations in place?
*
Yes
No
15. Fluid Texture Accommodations:
*
16. Food Texture Accommodations:
*
17. Dietary Restrictions in place?
*
Yes
No
18. Dietary Restrictions?
*
19. Dietary Supplements in place?
*
Yes
No
20. Supplement Notes:
*
21. Specific Nutrition Needs:
*
Yes
No
22. Nutrition Needs:
*
23. Positioning needs during or after eating?
*
Yes
No
24. Positioning notes:
*
25. Adaptive dining Equipment in place?
*
Yes
No
26. Dining Adaptive Equipment notes:
*
27. Behavior Support Plan in effect:
*
Yes
No
28. Behavior Support Needs:
*
29. Vision issues?
*
Yes
No
30. Vision risk plan in place?
*
Yes
No
31. Vision concerns (Select all that apply)
*
Blind
Blind in right eye
Blind in left eye
Nearsighted
Cataracts
Farsighted
Glaucoma
Wears Glasses
Macular Degeneration
Unspecified visual impairment
32. Vision notes:
*
33. Hearing issues?
*
Yes
No
34. Hearing Risk plan in place?
*
Yes
No
35. Hearing Concerns (Select all that apply)
*
Complete hearing loss
Left ear hearing loss
Right ear hearing loss
Uses hearing aids/ device
Other
36. Hearing notes:
*
37. Mobility needs?
*
Yes
No
38. Mobility/fall Risk Plan in place?
*
Yes
No
39. Mobility Concerns (Select all that apply)
*
Fall Risk
unsteady gait
History of frequent falls
Uses a walker
Uses a wheelchair
Uses crutches
Uses a cane
Uses a gait belt
Uses braces
Wears a helmet
Dependent on staff for lifts & transfers
Requires a Hoyer lift for transfers
Requires an accessible vehicle?
Other
40. Adaptive Equipment notes:
41. Mobility Notes:
*
42. Overall General Health;
*
Excellent
Good
Fair
Poor
43. Able to make health and medical decisions for day to day wellbeing?
*
Yes
No
44. Who supports you in making health and medical decisions?
*
45. Medication Administration needs:
*
46. Medication administration: (Select all that apply)
*
Whole
Orally
Crushed
In pudding
Other
47. Will take medication while being supported by Noble?
*
Yes
No
48. Does the individual understand why they are taking medication?
*
Yes
No
49. Medication Administration notes:
*
50. Personal Care Support Needs:
*
51. Other
52. Medical Appointment support needed:
53. Toilet Support Required:
*
Yes
No
54. Toileting support needed:
*
Needs reminders
Assistance after a bowel movement
Assistance with clothing
Assistance with wiping
Uses depends
Assistance with transfers
Assistance with hand washing
Requires a Hoyer Lift
Requires 2-person support
Other
55. Toileting Support Notes:
56. Independent in hygiene & grooming? (hair, shaving, deodorant, teeth, showers)
*
Yes
No
57. Type of support needed:
*
Needs reminders/ verbal prompts
Needs hand over hand support
Needs physical assistance
Other
58. Bathing Support needed:
*
59. Hygiene and grooming notes:
60. Diabetes diagnosis?
*
Yes
No
61. Diabetes Risk Plan in place?
*
Yes
No
62. Takes Insulin?
*
Yes
No
63. Takes medication for diabetes?
*
Yes
No
64. Checks Blood Sugar?
*
Yes
No
65. Independent in checking blood sugar?
*
Yes
No
66. Blood Sugar Check Notes:
*
67. What should we do if the blood sugar is low?
*
68. Diet restrictions due to diabetes?
*
Yes
No
67. Diet restriction needs?
*
68. For high/low blood sugar do we need to contact someone?
*
Yes
No
69. Who should be contacted?
*
72. Seizure diagnosis?
*
Yes
No
73. Seizure Risk Plan in place?
*
Yes
No
74. History of seizures?
*
Yes
No
75. Type of Seizures?
*
Absence (petit mal)
Tonic-Clonic (grand mal)
Myoclonic
Atonic
Clonic
Tonic
Other
76. Typical seizure activity:
*
77. How long do they typically last?
*
78. How often do they occur?
*
79. Is there an aura present?
*
Yes
No
80. Aura notes:
*
81. Are there triggers that bring on a seizure?
*
Yes
No
82. Trigger Notes:
*
83. What is typical after a seizure?
*
84. Do you take medication for seizures?
*
Yes
No
85. Do you use a vegus nerve stimulator?
*
Yes
No
86. Where do you keep your magnet?
87. What are the instructions for y our magnet?
88. Any other instructions to follow during a seizure?
89. Do you have allergies?
Yes
No
90. Do you have a life threatening allergy?
Yes
No
91. Do you have an EpiPen in place?
Yes
No
92. Where is the EpiPen stored?
93. Do you have an allergy risk plan in place?
Yes
No
94. What are your allergies?
95. Notes regarding your allergies?
96. Do you have constipation?
Yes
No
97. Constipation Risk Plan in place?
Yes
No
98. Has a Diagnosis of Chronic Or Recurrent Constipation?
Yes
No
99. Requires Routine Medication for Constipation?
Yes
No
100. Requires As-Needed Medication for Constipation?
Yes
No
101. Requires Fiber Supplements for Regularity?
Yes
No
102. Has a History of Bowel Obstruction?
Yes
No
103. Dehydration Issues?
Yes
No
104. Dehydration Risk plan in place?
Yes
No
105. History of Recurrent Dehydration:
Yes
No
106. Needs Prompts to Drink Adequate Fluids:
Yes
No
107. Frequent Refusals of Fluids:
Yes
No
108. Takes Medications That May Cause Dehydration:
Yes
No
109. Dental Health is good:
Yes
No
110. Dental Concerns:
Dentures
No teeth
Missing several teeth
Poor dental hygiene
Other
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Social & Spritual
Building friendships and relationships, leisure activities, personal networks and faith community.
01. Family, Friends & Relationships:
02. Cultural Preferences:
3. Religious involvement?
Yes
No
04. Religious Involvement Notes:
05. Natural Supports:
06. Who is important to you& how often do you see them?
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Advocacy & Citizenship
Building valued roles, making choices, setting goals, assuming responsibility and driving how one’s own life is lived.
01. Self Determination/rights – Level of Understanding
02. Level of consumer input in Plan Development
3. Registerd Voter?
Yes
No
4. What support do you need with voting?
05. Has a Health Care Representative
Yes
No
06. Has a Power of Attorney (POA)
Yes
No
07. Guardian/ POA/ HCR Involvement
8. Phone support?
9. Mail Suppoort?
Person Completing this form:
*
First Name
Last Name
Title:
*
Email Address:
*
example@example.com
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