JFS Intake Questionnaire

1

Name* This field is required.If you are a guardian submitting on behalf of a child, please provide your child's name.

First Name

Last Name

2

Date of Birth* This field is required.If you are a guardian submitting on behalf of a child, please provide your child's DOB.

Date

3

Phone Number* This field is required.If you are a guardian submitting on behalf of a child, please provide your phone number.

Please enter a valid phone number.

4

EmailIf you are a guardian submitting on behalf of a child, please provide your email address.

example@example.com

5

What is your zip code?* This field is required.

7

If other, please specify:

8

What is your current housing status?* This field is required.

Housed (rent or own)

Unhoused

Transitionally housed (staying with friends/family)

9

Please indicate your current source(s) of income.* This field is required.

Job

Disability

Other

No Income

10

Please describe anything else about your needs you'd like us to know.* This field is required.If you are a guardian submitting on behalf of a child, please include your name.

0/200

11

Do you identify as Jewish?* This field is required.JFS provides services to anyone, regardless of Jewish affiliation. This information is tracked for grant and funding purposes.

No

Yes

Prefer not to say at this time.

12

How did you hear about JFS?(optional)