Integrative Navigation Services Request Form

Email

This field is for validation purposes and should be left unchanged.

Email(Required)

First Name(Required)

Last Name(Required)

Phone(Required)

City

State

Zip Code

Birth Year

What is/was your cancer diagnosis?

When were you diagnosed?

If you have specific concerns that you would like to discuss with an Integrative Navigator, please list them here.

How did you hear about the Smith Center Integrative Navigation program?

Have you already spoken with or have you been referred to a specific Smith Center navigator? If so, please list their name.

Disclosure Statement and Liability Waiver for Smith Center Cancer Navigation Services

The goal of the Integrative Navigation Services at the Smith Center for Healing and the Arts (“Smith Center”) is to empower cancer patients to take a more active role in their healing and well-being through education, information, assistance with resources, and emotional and spiritual support. Individuals seeking Integrative Navigation Service (“participants”) are supported in a variety of ways. For example, Smith Center’s integrative cancer navigators (“navigators”):

Listen to participants, providing a compassionate and supportive ear;
Empower participants to better manage their care, including assisting them in compiling questions for their providers and supporting them in getting second opinions;
Assist participants in coping with their disease and treatment side effects;
Educate and support participants in selecting and accessing appropriate, evidence-based complementary therapies to use alongside medical treatments if they choose; and
Educate participants about the importance of coordinating all of their care with their physicians/medical teams.

Smith Center navigators are not medical or mental health professionals and do not provide medical or mental health advice. No information a navigator provides in the course of cancer navigation, including those regarding any complementary therapy, service, professional, or healthcare provider, shall be deemed an offer of medical advice or an endorsement. Smith Center navigators do not make referrals to healthcare providers; rather, navigators simply provide information about resources that the participants may benefit from, in order to assist the participants in making their own decisions.

Neither Smith Center nor any Smith Center navigator makes any representation that complementary therapies are intended to diagnose, treat, cure, or prevent any disease. Participants have the responsibility to inform their health care providers of their use of complementary therapies.

Smith Center navigators may ask participants for certain information, including contact information, cancer diagnosis, and other medical background information, in order to offer more helpful navigation services. All such information will be considered confidential and shared with other Smith Center navigators only to the extent necessary. You may choose to provide all or part of the requested information. By providing such information, you give Smith Center permission to maintain such information for two years after the completion of your participation. Smith Center will not provide your personal information to any third parties, including healthcare providers or other professionals without your full knowledge and approval.

If you have read and understand the above and wish to receive Integrative Navigation Services as a participant, please sign the Waiver and Release of Liability below.

Electronic Signature of Participant(Required)

Date of Signature(Required)

Disclosure Statement and Liability Waiver for Smith Center Cancer Navigation Services

OPTIONAL

Give the gift of hope