Navigation Assistance

Request For Community Navigator Services
Parent/Guardian/Caregiver Information

Primary Caregiver
Caregiver Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Communication Preference
Client Information

Individual Seeking Services
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Current Age
Choose One
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Who Does Client Live With?
Add text here
Diagnosis/Disability

Other
Is Client Enrolled In School?
Name of Current School
Type Name
Did Client Graduate from High School?
Graduation Year
xxxx
Are You A Current TLC Member?
Social Programs of interest
What Services Are You Currently Receiving?
What Services Are You Inquiring About?

Other
Med Waiver
What year did you apply for Med Waiver?
Consumer Directed Care Plus (CDC+)
Other Important Information

Please consider giving your input!
The Navigator program has been made possible through a grant from Marion County Hospital District and United Way. Please help us to keep accurate data and fulfill our reporting obligations to the grant. Your response to this area will have no bearing on whether or not you receive navigation services.
Sex
Ethnicity
Race
Please see the family income drop down box below and select the correct income that pertains to your family size. If the client is OVER the age of 21, you would select that the family size is "1" and use their income only.
Number of People in Household
Reminder: If client is OVER the age of 21, you would select the family size as "1" and use their income only
Income for 1 Person
Total Income
Income for 2 People
Total Income
Income for 3 People
Total Income
Income for 4 People
Total Income
Income for 5 People
Total Income
Income for 6 People
Total Income
Income for 7 People
Total Income
Income for 8 People
Total Income
TLC does not discriminate based on race, color, religion, gender, sexual orientation, national origin, age, or disabilities in hiring practices or provisions of service.
Should be Empty:

Request For Community Navigator Services

Parent/Guardian/Caregiver Information

Client Information

Other Important Information