Alexander Institute Questionaire

Some needs are easily identified; others are not. In order to plan for appropriate services, the Jewish Family Service Alexander Institute 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 Alexander Institute staff.

Confidential Special Needs Questionnaire

1 Do you or a member of your family have a special need?
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 Alexander Institute can help you, what would be your
     priorities? Please list in order of preference.
11 In what special needs area(s) are you most interested?
     (Check all that apply)
Social interaction programs
Referral resources
Support/respite groups
Please update me about new programs and services.
I am a special needs professional and would like to know more
      about the JFS Alexander Institute.

Personal Information

Your Name: 
Work Phone:  () - ext.
Home Phone:  () -
Cell Phone:  () -
Email Address: 

Please enter the code from above to submit this form.
(entry is NOT case-sensitive)

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