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Disability Services Questionaire

Some needs are easily identified; others are not. In order to plan for appropriate services, the Jewish Family Service Disability Services must understand the extent and scope of the special needs in Jewish families throughout Greater Houston. Please complete this questionnaire on-line, including your contact information, and follow the instructions at the bottom of the page to submit it confidentially. If you wish to speak with someone about your specific situation, call Jewish Family Service at 713-667-9336 and ask to speak with a member of the Disability Services staff.

Confidential Special Needs Questionnaire

1 Do you or a member of your family have a special need?
Child
Spouse
You
Other
Gender:
Male
Female
 
2 What is the disability?
 
3 Age:
0-5    6-10    11-15    16-20    21-30
31-40    41-50    51-60    60+
 
4 Residence:
At home    Residential facility
Independent   Other
 
5 Is there a need for special transportation?
Yes    No
If yes, what kind?
 
6 What are your greatest concerns for the future of your
     loved one?
 
7 What services do you need now?
 
8 What services do you anticipate needing in the future?
 
8 Is having a Jewish service provider important to you?
Yes    No
If yes, for what services?
 
10 If JFS Disability Services can help you, what would be your
     priorities? Please list in order of preference.
1.
2.
3.
 
11 In what special needs area(s) are you most interested?
     (Check all that apply)
Education
Social interaction programs
Referral resources
Support/respite groups
Other
Please update me about new programs and services.
I am a special needs professional and would like to know more
      about the JFS Disability Services.

Personal Information

Your Name: 
Address: 
City: 
State: 
Zip: 
Work Phone:  () - ext.
Home Phone:  () -
Cell Phone:  () -
Email Address: 
Note: If you are human, do NOT fill out the field below.