Request For Services Screening

Do you have critical or urgent needs in any of the following:

Medical Issues Food Utilities Housing Medical Insurance None
Are you 60 years old or older? *

Yes No

Do you have family and/or friends who you can rely on support? *

Yes No
Any additional information:
Do you have any concerns about your housing or home safety? *

Yes No
Any additional information:
Do you feel like your health needs are being addressed? *

Yes No
Any additional information?
Do you have difficulty remembering or concentrating on day to day activities? *

Yes No
Any Additional Information

During the last two weeks have you been bothered by feeling down, sad, hopeless?

Yes No
During the last two weeks, how often have you felt down, depressed, or hopeless? *
Please select from the list.

During the past two weeks have you been bothered by having little interest or pleasure in doing things?

Yes No
During the past two weeks, how often have you been bothered by having little interest or pleasure in doing things? *
Please select from the list.
In the past month have you had thoughts of killing yourself? *

Yes No

Please be aware that JFS does not have 24 hour coverage. We will get back to you as soon as possible. If you have emergent mental health needs please call 911 or the National Suicide Hotline at 1-800-273-8255

Is there anything else you would like us to know about your situation?
Should be Empty: