I am in Need of Assistance IF THIS IS A MEDICAL OR MENTAL HEALTH EMERGENCY PLEASE CONTACT 911 IMMEDIATELY Name Home Phone Cell Phone Address Email Address Date of Birth Please briefly describe the situation and the type of assistance being requested: Is this a: Is this a: Self-Referral Referral for someone else. Please complete the following: Name Phone # Email address: Relationship to person you are referring: Organization, if applicable: Are you or have you previously received services from JFS? Are you or have you previously received services from JFS? No Yes Please describe the services received and approximately when you received the service 5 + 15 = Submit
