JFS Intake Questionnaire

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Welcome!

Please submit your information. If you are eligible for services, an Intake Coordinator from JFS will contact you as soon as we are able. If you are a case manager trying to connect your client to services, please ensure they complete this form themselves.

12Questions

1
Name* This field is required.Name of person looking to receive services. If you are a guardian submitting on behalf of a child, please provide your child's name instead of your own.
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
Month
Day
Year
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.
6
What are you seeking assistance for today?* This field is required.JFS does not have emergency housing, rental or utilities assistance. Please reach out to United Way 2-1-1 if looking for those resources. JFS offers assistance for the following areas. Please select any that apply to you at this time.
Aging in Place / Older Adult Needs
Benefit application assistance (KC Water Fund, SNAP, LIHEAP, etc.)
Case management
Counseling
Employment resources
Food assistance
Health care resources (including AccessKC)
Jewish spiritual care or Chaplaincy
Transportation (ages 60+)
Home maintenance (ages 60+)
Partnering for Stability Coaching Program
Other
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
Huge
Large
Normal
Small
Ok
Ok
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)
Please Select
Other community agency (school, social service agency, etc.)
Community event
Friend / family member
Internet search
Jewish Congregation
Medical personnel (doctor, nurse, social worker)
Previous client
Social media post
Should be Empty:

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