Universal Screening

This screening is not intended to communicate emergency safety concerns. If you are at risk harming yourself or others or experiencing an emergency, contact 911 or proceed to your nearest emergency room

If you are in Washtenaw County and this is a mental health crisis, another resource is to call the county Crisis Team at 734-544-3050. Please note, JFS is not licensed to provide substance use therapy at Thrive Counseling.

Thrive is unable to provide substance use treatment.

Please go to samhsa.gov, findtreatment.gov, or call 1-800-662-HELP (4357) to find resources.
Are you in need of other (non-counseling) JFS services?

YesNo

Do you currently have health insurance coverage?*

YesNo

Insurance Company Name*
Subscriber Name*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Date
Contract or Recipient ID Number*
Group Policy Number*
Effective Date

MonthDayYear
Date
Do You Have Secondary Insurance?*

YesNo

Insurance Company Name*
Subscriber Name*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Date
Contract or Recipient ID Number*
Group Policy Number*
Effective Date

MonthDayYear
Date

Do you have critical or urgent needs in any of the following (check all that apply):

Medical IssuesFoodUtilitiesHousingMedical InsuranceNone
Is there anything else you would like us to know about your situation?
Are you 60 years old or older?*

YesNo

Do you have family and/or friends whom you can rely on for support?*

YesNo
Any additional information?
Do you have any concerns about your housing or home safety?*

YesNo
Any additional information:
Do you feel like your health needs are being addressed?*

YesNo
Any Additional Information
Do you have difficulty remembering or concentrating on day to day activities?*

YesNo
Any additional information:

This screening is not intended to communicate emergency safety concerns. If you are at risk harming yourself or others or experiencing an emergency, contact 911 or proceed to your nearest emergency room.

Additional crisis resources include:

National Suicide Hotline: call or text 988.

In Washtenaw County: Community Mental Health Crisis team (734) 544-3050

Michigan Medicine Psychiatric Emergency Services (734) 936-5900.

Please be aware that JFS's hours of operation are Monday-Thursday 9am-5pm, Fridays 9am-3pm and is closed on holidays.

*Due to staffing there will be a delay in responding*
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