Arabic Universal Screening

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

If you are in Washtenaw County and this is a mental health crisis, another resource is to call the county Crisis Team at 734-544-3050. Please note, JFS is not licensed to provide substance use therapy at Thrive Counseling.

Thrive is unable to provide substance use treatment.

Please go to samhsa.gov, findtreatment.gov, or call 1-800-662-HELP (4357) to find resources.
Are you in need of other (non-counseling) JFS services?

Do you currently have health insurance coverage?

Insurance Company Name
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contract or Recipient ID Number
Group Policy Number
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do You Have Secondary Insurance?

Insurance Company Name
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contract or Recipient ID Number
Group Policy Number
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Do you have family and/or friends whom you can rely on for support?
Any additional information?
Do you have any concerns about your housing or home safety?
Any additional information:
Do you feel like your health needs are being addressed?
Any Additional Information
Do you have difficulty remembering or concentrating on day to day activities?
Any additional information:
Please list any other agencies you are currently working with:

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.

In Washtenaw County: Community Mental Health Crisis team (734) 544-3050

Michigan Medicine Psychiatric Emergency Services (734) 936-5900.

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