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Community Navigator Program
Enroll a Family in Community Navigator Program/Inscribir Familias Aqui
Sibling Support
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Community navigator Program: Fill out this form to enroll or request More information about the program.
*
Indicates required field
Parent/Caregiver Name
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First
Last
Phone Number
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Email
*
Languages Spoken:
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Zip Code
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County
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Child's Name
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Child's Date of Birth
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Developmental Disability, if known
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Who referred you to the Community Navigator Program, if known?
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Please list the name of the person who referred you to Mind The Gap, if known
From the topics below what are you interested in learning more about?
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Condition/diagnosis specific Info. (Autism, ADHD, Down Syndrome, etc.)
Communication development
Navigating health systems
Behavior
Parents rights and child advocacy
Stigma
Healthy lifestyle/self care
Other (For example: translation services, transportation, and preparing your home for providers.)
All of the above
Select all that apply
How did you hear about Community Navigator Program?
*
Warmline website
Warmline newsletter
Facebook/social media
Flyer
Regional center/Infant Development Program
Other local agency
Other - Please specify in comment box below
Comment
*
Pease use this space to ask any questions or tell us more about your child/family.
Name of professional making the referral (if applicable)
*
Agency
*
Email address
*
Submit
Programa de Navegación Comunitaria
Formulario de Contacto
*
Indicates required field
Nombre
*
First
Last
Correo Electronico
*
Numero de Contacto
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Idioma preferido
*
Codigo Postal
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Nombre de Nino o Nina y Fecha de Nacimiento
*
Condado
*
Yolo County
Sacramento County
Su hijo/hija tiene discapacidad de desarollo?
*
Si
No
No estoy segura
¿Quién la refirió al programa?
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Por favor indique el diagnostico de su hijo/hija.
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Que es lo que mas le interesa en aprender en el programa?
*
informacion especifica sobre el diagnostico
desarrollo de la comunicacion
navegando por los sistemas de salud
comportamiento
derechos de los padres y abogacia
estigma de discapacidad
creando un estilo de vida saludable
Other
Como se entero de nuestro programa ?
*
WarmLine Family Resource Center
Boletin de WarmLine
Facebook/medios sociales
Volante
Centro Regional/Programa Infantil
Grupo de Apoyo
Comentarios Adicionales
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Nombre del profesional haciendo la remisión (si corresponde)
*
Agencia
*
Correo Electronico
*
Submit