Jewish Family Service

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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
Do you or a member of your family have a special need?
Child Spouse You	Other
Gender: Male Female

What is the disability?

Age:
0-5 6-10 11-15 16-20 21-30 31-40 41-50 51-60 60+

Residence:
At home Residential facility Independent Other

Is there a need for special transportation?
Yes No
If yes, what kind?

What are your greatest concerns for the future of your loved one?


What services do you need now?


What services do you anticipate needing in the future?


Is having a Jewish service provider important to you?
Yes No
If yes, for what services?

If JFS Disability Services can help you, what would be your priorities? Please list in order of preference.
1. 2. 3.

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

REELABILITIES: HOUSTON DISABILITIES FILM FESTIVAL 2013

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Confidential Special Needs Questionnaire

Personal Information