Ohio Universal Screening

  • JFS Request For Services

    This form is not intended to communicate emergency safety concerns. If you are at risk for harming yourself or others or experiencing an emergency, contact 911 or go to your nearest emergency room.
  • Are you filling this screening out for yourself or on behalf of someone else?*
  • Are they aware of this screening being submitted?*
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  • Permission for staff to leave a detailed voicemail?*

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  • For people under 18 we require the following:

  • JFS usually communicates in English but is happy to assist in other languages. Are you in need of language interpretation of phone calls/emails?*

  • Demographics

    The following questions are for reporting purposes only and in no way impact eligibility for programs. Jewish Family Services provides services for all residents of Washtenaw County. We are committed to providing affordable, accessible, holistically-oriented and culturally sensitive care to our clients, whatever their identification, affiliation, lifestyle, background, race, religious creed, or national origin.
  • What is your annual income?*
  • Source of Income (please mark all that apply):*

  • What (if any) public assistance do you receive?*
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  • Over the past 2 weeks, how often have you been bothered by any of the following problems: Little interest or pleasure in doing things ?*
  • Over the past 2 weeks, how often have you been bothered by any of the following problems: Feel down, depressed or hopeless ?*
  • Do you have critical or urgent needs in any of the following (check all that apply):
  • Has a lack of transportation kept you from attending medical appointments or from work, or from getting things you need for daily living?
  • Do you/your family worry about whether your food will run out and you won't be able to get more?
  • Are you currently having issues at home with your utilities such as your heat, electric, natural gas or water?
  • Are you worried about losing your housing, or are you homeless?
  • Are you worried someone may hurt you or your family?
  • Are you 60 years old or older?*
  • Do you have family and/or friends whom you can rely on for support?*
  • Do you have any concerns about your housing or home safety?*
  • Do you feel like your health needs are being addressed?*
  • Do you have difficulty remembering or concentrating on day to day activities?*

  • 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.

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

     

     

  • Should be Empty: