GAC Family Navigator Intake Form

* Required Fields

Please Tell us about yourself

Today's Date

First Name

Last Name

Home Phone

Cell Phone

Address

City

State/Province

Zip/Postal Code

Primary Language

If Other, Please specify

If you want interpreter services for your discussion with a Family Navigator, please select the language needed **NOTE that it takes a minimum of 2 weeks to arrange interpreter services.

Your Income Level

Race/Ethnicity

Relationship of caller to Subject

Topics you would like to discuss a Family Navigator

(check all that apply)

School

Home

Community

Medical

Adult Issues like Transition, Employment, Housing, Transportation

Other (please specify)

Please provide details about the topic you wish to discuss, so the Navigator can be prepared

Agreements and Releases

1. I understand that the Family Navigator will:

educate and empower me to help me succeed
provide information about relevant systems, regulartions, and laws
provide connection to community resources
help me learn to become a better advocate for myself

2. I understand that the Family Navigator will not:

give legal advice or act as my attorney
provide medical advice and is not a doctor or medical professional
attend schooll, life plan, or other meetings on my behalf
make decisions about services or supports for me

I understand what the Family Navigator Will and Will NOT Do, as stated above

3. I understand that the completion of this form activates my free membership in AutismUp. This will place me on the email list for AutismUp.

4. Please read and select answer below: I release and forever discharge and hold harmless AutismUp, their successors, and assigns from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may herafter arise from the services provided by the Family Navigator. I agree that this agreement is binding on me (the person named at top of form), the members of my family and spouse (if any), my estate, heirs, administrators, successors, assigns, and personal representatives. I have read and understand this agreement. I fully understand that by choosing "I agree", that I surrender valuable rights, including but not limited to the right to so. I do so freely and voluntarily.

Select response:

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AutismUp * Located at the Golisano Autism Center, 50 Science Parkway, Rochester NY 14620 *
(585) 248-9011 * www.autismup.org * [email protected]