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*

PhoneE-MailUS Mail
Client Information

Individual Seeking Services
Name*

First NameLast Name
Birth Date

MonthDayYear
Date
Current Age
Choose One*

Client address is same as caregiverClient has different address
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*

Down SyndromeAutismCerebral PalsySpina BifidaPrader-Willi SyndromeIntellectual DisabilityPhelan McDermid SyndromeOther
Is Client Enrolled In School?

YesNo
Name of Current School
Type Name
Did Client Graduate from High School?

YesNo
Graduation Year
xxxx
Are You A Current TLC Member?

YesNoNo, but I would like more information on TLC.
Social Programs of interest*

SportsArtsCommunity EngagementHorse back riding
What Services Are You Currently Receiving?

Day ProgramSocial Group(s)Sports/Special OlympicsCompanion CareGroup HomeNone
What Services Are You Inquiring About?*

Local Community Social ProgramsCommunity Day ProgramsMed WaiverCDC+Vocational RehabilitationSSIGuardianshipTransportationHousingOther
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.
Sex

MaleFemale
Ethnicity

HispanicNon Hispanic
Race

WhiteBlack/African AmericanAsianAmerican Indian/Alaskan NativeNative Hawaiian/Other Pacific IslanderAmerican Indian/Alaskan Native & WhiteAsian & WhiteBlack/African American & WhiteAmerican Indian/Alaskan Native & Black/African AmericanOther 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
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.
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Request For Community Navigator Services

Parent/Guardian/Caregiver Information

Client Information

Other Important Information