JFNA Intake Form for Financial Assistance (Francenia Ponder)

In-Take Form for JFNA Financial Assistance Recipients
Date*

MonthDayYear
Date
Client Name*
Client Address*
Client Phone #*
Client Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Is a primary family caregiver involved:*

YesNo
If yes, please provide:
Name
Phone #
Email
example@example.com
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)*

Family CaregiverFriendProfessional
Name
Phone #
Email
example@example.com
If applicable, provide:
Organization Name
Position
Client Demographics
County:*

ButtsCherokeeClaytonCobbCowetaDeKalbDouglasFayetteFultonGwinnettHenryPauldingRockdaleUnknown
If Fulton:

North FultonCity of AtlantaSouth Fulton
If living outside metro Atlanta Counties:

YesNoN/A
Additional demographic questions below are for reporting purposes only and do not affect clients’ ability to receive services.
Race:*

African-AmericanHispanicCaucasianAsianPacific IslanderNative AmericanUnknownOther
Gender:*

MaleFemaleOther
Jewish:*

YesNoUnknown
Veteran*

YesNo
Chronic Homeless:*

YesNo
Income Level:
Annual Income: *
Assets (not including home): *
Assistance Requested (please check all that apply):*

Appliance Repair/ReplacementProfessional CargivingClothingDental AssistanceFood AssistanceFuneral & Burial ExpensesHousehold & Personal Care SuppliesHousehold FurnishingsHousing AssistanceHousing ModificationsHousing RepairsLegal CostsMedical AssistancePet CareTranslation & InterpretationTransportationUtility AssistanceUtility Repair & ReplacementOther
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.*

3 High2 Moderate1 Low
Please explain why you made your selection: *
Please check the type of documentation you are providing below.
Proof of Age (Government ID):

Driver’s licensePassportState IDOther
Proof of Income:*

Social Security StatementBank statementPension statementOther
Please upload documentation for proof of age (driver’s license, state ID), income (social security statement, bank statement, or pension statement, etc.)
Please upload Files Here...*

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

African American or Black Older AdultAsian American Older AdultLatin American Older AdultAmerican Indian, Alaska Native, Native Hawaiian Older AdultLGBTQ Older AdultFamily Caregiver of Older AdultHolocaust SurvivorFirst Responder Older AdultImmigrant or Refugee Older AdultOlder Adult Crime SurvivorOlder Adult Disaster SurvivorOlder Adult Domestic or Sexual Violence SurvivorOlder Adult with DisabilitiesVeteran Older AdultOther (please indicate)
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?*

YesNo
Have you received financial assistance in the past?*

YesNo
If yes, what was your experience like?
Are you currently receiving any financial assistance from other organizations, friends, and/or family?*

YesNo
Have you explored other sources of financial assistance or support? Please check all that apply:

OrganizationsPlease List
Friends/FamilyReligious institution or group
Government ResourcesPlease List
OtherPlease List
How will the financial assistance impact your current financial situation and budget? Check all that apply.*

Maintain or improve financial stabilityReduce debt burdenCover unexpected expensesTemporary relief from financial stressOther
What steps do you plan to take to improve your financial situation and become more financially stable in the long-term?*

Increase Income (seek higher-paying opportunities, enhance job skills, take on additional work)Reduce Expenses (create and stick to a budget, cut down on spending, access benefits that qualify for to reduce expenses)Debt Management (develop repayment plan for existing debts, prioritize high interest debts for faster payoff, negotiate with creditors to lower interest rates, explore debt consolidation/refinancing options)Savings & Investments (establish an emergency fund for unexpected expenses)Financial Education (attend financial literacy workshops, seek professional help)Other
On a scale of 1-4 with 4 being highest, how would you rate your level of stress and anxiety over your financial situation?*

4: Very high (extreme stress and anxiety related to finances/facing severe financial hardship and crisis)3: High (Significant stress and anxiety related to finances/struggling to meet financial obligations and cover basic needs)2: Moderate (Some occasional stress and anxiety related to finances/worries about meeting financial obligations but generally manageable)1: Low (Minimal stress and anxiety related to finances/feeling confident and secure about financial future)
Please provide any other information about your financial situation or need for assistance?
I understand that the services provided to me are made possible by a grant from The Jewish Federation of North America (JFNA) Center on Aging and Trauma.
Please INITIAL.
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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In-Take Form for JFNA Financial Assistance Recipients

Client Demographics