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Intake/Information Sheet

Jewish Family Services - Multiple Programs
6718 Patterson Ave.
Phone 804-282-5644
Fax 804-673-2061
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
* Date
Person completing this form contact information (if not the client)
Name of Person Filling out this form
Phone Number of Person Filling out Form
* How did you hear about JFS?
Adult Care Facility   Current or Former Svc. At JFS   Insurance Referral  
MD   Mailing/Flyer   Self  
Advertising   Friend/Family   Internet  
United Way   CAAA   Govt. Agency  
Jewish Affiliation   Mental Health   Prof Visit/Presentation  
Community Svc. Agency   Home Health Agency   Ref’d by JFS Client  
Religious   Yellow Pages   Court/Lawyer  
Hospital Personnel   Ref’d by JFS Staff/Board School Professional   Other  
Referral Source Name
Referral Source Phone Number
Fax Number
Name of Parent/Guardian
Phone Number of Parent/Guardian
Email of Parent/Guardian
Client's Personal Information
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Email:
* Preferred Contact Number
Cell  Home  Other 
  
* Preferred Method of Communication
email   phone   text  
Any     
* At which number can we leave a message?
* Text/Voice Message Authorization
JFS collects demographic information for use in reporting for grants, The United Way and determination of self pay fees.
* County
* Marital Status
* Household Income
* Household Size    Enter how many household members depend on the income that you entered
* Gender
* Veteran Status
Other
* Religion
Other
* Race
Other
* Ethnicity
Describe the reason for the appointment request and who should be called to set an appointment
* 
Insurance information
Insurance information    Enter insurance information
  * Primary Insurance Secondary Insurance Third Insurance
Insurance Name
ID (Member ID)
Group
Policy Holder Name (if not self)
Policy Holder Date of Birth (If not self)
If Medicare, Do you have Part B benefits?
EAP information    Enter EAP information if applicable
  EAP information
EAP Name
EAP Phone Number
EAP Authorization Number
Authorization Start Date
Authorization End Date
Number of Sessions
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Cancel" button to exit without saving recent updates on this form.