Navigation Assistance

Request For Community Navigator Services
Parent/Guardian/Caregiver Information

Primary Caregiver
Caregiver Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Communication Preference *

Phone E-Mail US Mail
Client Information

Individual Seeking Services
Name *

First Name Last Name
Birth Date

Month Day Year
Date
Current Age
Choose One *

Client address is same as caregiver Client has different address
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Client Lives With *
Select from drop down menu
Who Does Client Live With?
Add text here
Diagnosis/Disability *

Down Syndrome Autism Cerebral Palsy Spina Bifida Prader-Willi Syndrome Intellectual Disability Phelan McDermid Syndrome
Explain Other
Is Client Enrolled In School?

Yes No
Name of Current School
Type Name
Did Client Graduate from High School?

Yes No
Graduation Year
xxxx
Are You A Current TLC Member?

Yes No No, but I would like more information on TLC.
What Services Are You Currently Receiving?

Day Program Social Group(s) Sports/Special Olympics Companion Care Group Home None Other
Explain Other
What Services Are You Inquiring About? *

Local Community Social Programs Community Day Programs Med Waiver CDC+ Vocational Rehabilitation SSI Guardianship Transportation Housing
Social Programs of interest

Sports Arts Community Engagement Horse back riding
Med Waiver

I would like more information about the Med Waiver program. I need assistance completing the Med Waiver application. We have applied for Med Waiver and are on the waiting list. Circumstances in our home have changed and we need to update our application information.
What year did you apply for Med Waiver?
Consumer Directed Care Plus (CDC+)

What is CDC+? I am currently enrolled in Med Waiver. I have a support coordinator. I am currently on the Med Waiver waiting list. I am interested in transitioning from Med Waiver to CDC+. I am interested in a mentor to assist with processing documents for 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.
Ethnicity

Hispanic Non Hispanic
Race

White Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native & White Asian & White Black/African American & White American Indian/Alaskan Native & Black/African American Other Multi-Racial
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
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.
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Request For Community Navigator Services

Parent/Guardian/Caregiver Information

Client Information

Other Important Information