Wise Request For Services Screening

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  • Request For Assistance Screening

  • Which of the following apply:

  • Date of Birth*
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  •  -
  • Is it okay to leave a voicemail?*

  • 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.
  • Immigration Status*

  • Household Income per year:*

  • Source of Income (please mark all that apply):*

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

  • Are you 60 years old or older?*
  • Do you have family and/or friends who you can rely on 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?*
  • During the last two weeks have you been bothered by feeling down, sad, hopeless?*
  • During the past two weeks have you been bothered by having little interest or pleasure in doing things?*

  • Please be aware that we do 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

  • Should be Empty: