Request For Services Screening

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

Medical IssuesFoodUtilitiesHousingMedical InsuranceNoneOther
Are you 60 years old or older?*

YesNo

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

YesNo
Any additional information:
Do you have any concerns about your housing or home safety?*

YesNo
Any additional information:
Do you feel like your health needs are being addressed?*

YesNo
Any additional information?
Do you have difficulty remembering or concentrating on day to day activities?*

YesNo
Any Additional Information

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

YesNo
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?

YesNo
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.

Is there anything else you would like us to know about your situation?
Please be aware that JFS is not open 24 hours, hours of operation are Monday-Thursday 9am-5pm, Fridays 9am-3pm and is closed on holidays. All requests will be responded to on the next business day. If you are feeling unsafe, thinking of harming yourself or others please call 911 or head to your local emergency department.

Additional crisis resources include: Washtenaw County Crisis Line (734) 544-3050, Crisis text number (text “HOME” to 741741), Psychiatric Emergency Services (734) 936-5900.
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Demographics