GAC Family Navigator Intake Information
RequiredRequired Question(s)
Required 1.
Please tell us about you:

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:
Cell Phone:
School District:

Required 2.

Relationship to Individual:

Self
Parent
Legal Guardian
Extended Family Member
Care Coordinator/Case Manager
Other  
Required 3.

Primary Language: 

English
Spanish
ASL
Other  
Required 4.

Household Income: 

Less than $20,000
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 to $199,999
$200,000 and above
Prefer not to answer
Required 5.

Ethnicity:

White
Hispanic/Latino
African American
Asian
Pacific Islander
Prefer Not to Answer
Other  
Required 6.

Child's First Name: 

 

50 characters left.
Required 7.

Child's Last Name:

 

50 characters left.
Required 8.

Child's Date of Birth:

 

50 characters left.
Required 9.

Primary Diagnosis: 

Autism Spectrum Disorder
ADHD or ADD
Anxiety Disorder
Blindness or Visual Impairment
Cerebral Palsy
Depression
Down Syndrome
Fetal Alcohol Syndrome
Deafness or Hearing Impaired
Intellectual Disability
Language or Speech Disorder
Learning Disability
Mobility Impairment
Nonverbal Learning Disorder
Sensory Processing Disorder
Spina Bifida
Tourette Syndrome
Other  
Required 10.

Secondary Diagnosis: 

Autism Spectrum Disorder
ADHD or ADD
Anxiety Disorder
Blindness or Visual Impairment
Cerebral Palsy
Depression
Down Syndrome
Fetal Alcohol Syndrome
Deafness or Hearing Impaired
Intellectual Disability
Language or Speech Disorder
Learning Disability
Mobility Impairment
Nonverbal Learning Disorder
Sensory Processing Disorder
Spina Bifida
Tourette Syndrome
Other  
Required 11.

Primary Insurance: 

Aetna
BlueCross and BlueShield WNY
Cigna
Excellus BCBS
Fidelis
Humana
iCircle Care
Medicaid
Medicare
MVP
TriCare
Univera
WellCare
YourCare
Other  
Required 12.

Secondary Insurance: 

Aetna
BlueCross and BlueShield WNY
Cigna
Excellus BCBS
Fidelis
Humana
iCircle Care
Medicaid
Medicare
MVP
TriCare
Univera
WellCare
YourCare
None
Other  
Required 13.

I hereby authorize the Golisano Autism Center for use and disclosure of demographic information only, pertaining to the child listed above, for the following reasons only:

To establish eligibility for programs and services located at the GAC
To maintain enrollment data for GAC agencies
To facilitate referral to agencies and programs located at the GAC
Required 14.
I am interested in learning about the following programs and services located at the Golisano Autism Center:
Fitness and Recreation Classes (AutismUp)
Parent Support and Information (AutismUp)
Day Programs for Adults (Arc of Monroe, CP Rochester)
Employment Services (Holy Childhood, Rochester Rehabilitation)
Preschool Programs (Happiness House)
Early Intervention (Room to Bloom)
Outpatient Clinical Services (CP Rochester)
School (Mary Cariola, Kessler Center
Adult Housing Options (Monroe Housing Collaborative)
OPWDD Care Coordination (Prime Care)
Other  
  • Comment:

  • 500 characters left.
Required 15.
When I meet with a Navigator, I would like information and assistance with the following topics:
School
Home
Community
Medical
Adult
Other  
  • Comment:

  • 500 characters left.
Required 16.
I understand that the Family Navigator will:
1. educate and empower me to help my child succeed
2. provide information about relevant systems, regulations, and laws
3. provide connection to community resources 
4. help me learn how to become a better advocate for my child
I understand and agree
I do not understand and cannot agree. I understand that this means I cannot utilize the services of the Family Navigator.
Required 17.

I understand that the Family Navigator will not:
1. give legal advice or act as my attorney 
2. provide medical advice and is not a doctor or medical professional 
3. attend CSE or school meetings on my behalf 
4. make decisions about services or supports for my child 

I understand and agree
I do not understand and cannot agree. I understand that this means I cannot utilize the services of the Family Navigator.
Required 18.
I release and forever discharge and hold harmless AutismUp, the Golisano Autism Center, and their successors, and assign from any and all liability, claims, and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from the services provided by the Family Navigator. I agree that this agreement is binding on the undersigned, 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 understand that by signing this agreement, I surrender valuable rights, including but not limited to my right to sue.  I do so freely and voluntarily.
I agree
I do not agree. I understand that this means I cannot utilize the services of the Family Navigator.