Jewish Family Service

Social services for Jewish Nazi victims have been supported by a grant from the Conference on Jewish Material Claims
Against Germany

Member of:

The Network of Jewish Human Service Agencies

This Hurricane Harvey recovery project was funded in part by a grant from the American Red Cross.

Therapy Request

JFS' Counseling department is proud that we have been able to continue to serve the community without interruption since the start of the pandemic. Due to the pandemic, the need for quality mental health care services has greatly increased. In order to ensure that we can serve as many people in need as possible during this stressful time, we want our clients to know that we will be more stringent in following established appointment cancellation and attendance policies. This will help us make sure that we can help as many individuals as possible in a timely fashion. Please be aware that we continue to have a waitlist for therapy services and therefore we may not be able to accommodate all of a client's requests and/or needs. In order to make sure that we are able to help individuals and families get the help they need, there may be times that we work together with a person requesting services to get them connected with one of our trusted community partners.

Thank you for your support and understanding. We, will get through this, together!

**This form is for Behavioral and Mental Health Counseling**

All information provided in this form will be submitted directly to the Jewish Family & Children's Mental Health Program and will be kept strictly confidential. If this is an emergency please call 911 or the 24 hour helpline at 713-970-7000 or text "START" to 741-741. All requests submitted will be followed up within one business day.

JFS seeks to provide services to the 29 surrounding zip codes. To maintain the best, ethical and clinical practice, and to ensure greatest level of confidentiality to protect our clients, JFS employees, JFS board members, and/or their family members will be referred elsewhere for most services. JFS intake staff members will assess, consult and make appropriate referrals for those that we cannot directly serve.

Client Information

Referred Client's Name:
child adult
Phone:
Address:
City:
State:
Zip Code:
Email:
Date of Birth:
Race:
Religion:
Client's Gender: Male Female Other

Pronouns client prefers: He She They

Marital Status: Single Married Widowed
Cohabitating Divorced Separated

Primary Language: English Spanish Other

What are you seeking counseling for?

Do you currently receive any other mental health services? No Yes

Have you received mental health services in the past? No Yes

Any current legal issues we should know about?
(divorce, child custody, DWI, assault, etc.) No Yes

Any safety concerns (restraining orders)? No Yes

Any current medical issues that are important for us to know about? No Yes

Did you flood in 2017? No Yes

Are you referred by your EAP? No Yes

Are you New to JFS Houston? No Yes

Are you New to Counseling services at JFS? No Yes

Until deemed appropriate to reopen the building, JFS will ONLY serve clients via our HIPAA compliant online provider (Zoom) or by phone.

Best days and times for appointments:
Who referred you to us:

Payment Information

Please select one of the following:

I HAVE health insurance
I do NOT have health insurance

For those individuals/families that do have health insurance, please provide the following:

Insurance Company Name:
Policy Holder:
Date of Birth of Policy Holder:
Phone Number On The Back Of The Card:
Member ID#:
Group#:

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Therapy Request

Client Information

Caregiver Information

Payment Information