JFNA Intake Form for Financial Assistance V2024 (Georgia Gunter)

  • In-Take Form for JFNA Financial Assistance Recipients

    Aviv Older Adult Services
  • Date*
     / /
  • Format: (000) 000-0000.
  • Date of Birth*
     / /
  • Is a primary family caregiver involved:*

  • If yes, please provide:

  • Format: (000) 000-0000.

  • If the person completing this form is not the client, please provide the following information below about yourself.

  • Relationship to Client: (if you are the Family Caregiver, you may skip down to Client Demographics)*
  • Format: (000) 000-0000.

  • If applicable, provide:

  • Client Demographics

  • County:*
  • If Fulton:
  • If living outside metro Atlanta Counties:

  • Additional demographic questions below are for reporting purposes only and do not affect clients’ ability to receive services.

  • Race:*
  • Gender:*
  • Jewish:*
  • Veteran*
  • Chronic Homeless:*

  • Income Level:

  • Assistance Requested (please check all that apply):*

  • Definition of Levels of Urgency for JFNA Financial Assistance Intake Form

     

    Level 1: Low Urgency for Financial Assistance - A Level 1 level of urgency for financial assistance indicates a relatively low level of immediate need or time sensitivity. Individuals or organizations categorized at this level may require financial assistance, but their situation does not pose an immediate threat or risk. They have some time to explore options, seek assistance, or consider alternative solutions before their financial situation becomes critical.

     

    Level 2: Moderate Urgency for Financial Assistance - A Level 2 level of urgency for financial assistance suggests a moderate level of immediate need or time sensitivity. Individuals or organizations classified at this level face a more pressing financial situation that requires timely intervention. While there may still be some time to address the issue, the need for assistance is becoming more urgent, and a delay in securing financial support could lead to increased difficulties or negative consequences.


    Level 3: High Urgency for Financial Assistance - A Level 3 level of urgency for financial assistance represents the highest level of immediate need or time sensitivity. Individuals or organizations classified at this level are in a critical financial situation that demands immediate action. They face significant and time-sensitive financial challenges, such as impending eviction, utility shut-offs, medical emergencies, or other urgent circumstances. Rapid assistance and intervention are essential to prevent further harm or severe consequences.

  • On a scale of 1-3, with 3 being highest need, please indicate your level of urgency for financial assistance.*

  • Please check the type of documentation you are providing below.

  • Proof of Age (Government ID):
  • Proof of Income:*

  • Please upload documentation for proof of age (driver’s license, state ID), income (social security statement, bank statement, or pension statement, etc.)

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  • Identify the client’s primary “trauma” category:*

  • These questions provide staff with additional information and help staff to prioritize clients’ need but does not prevent clients from accessing services.

  • Is the client willing to participate in a follow up survey after receiving financial assistance?*
  • Have you received financial assistance in the past?*
  • Are you currently receiving any financial assistance from other organizations, friends, and/or family?*
  • How will the financial assistance impact your current financial situation and budget? Check all that apply.*
  • What steps do you plan to take to improve your financial situation and become more financially stable in the long-term?*
  • On a scale of 1-4 with 4 being highest, how would you rate your level of stress and anxiety over your financial situation?*

  • Jewish Family & Career Services | The Max M. Cuba Social Service Center 4549 Chamblee Dunwoody Rd, Atlanta, GA 30388 | P. 770.677.9300 | F. 770.677.9400 | JFCSatl.org | info@jfcsatl.org

  • JF&CS is a proud partner of the Jewish Federation of Greater Atlanta and the United Way of Greater Atlanta. Accredited by the Commission on Accreditation of Rehabilitation Facilities.

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