www.jfshouston.org
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34.253.101.190
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Submitted URL: https://r20.rs6.net/tn.jsp?f=001M9ygxeRzHcnwzEU-gt6b4Iw4pmaMYyHviaZzPV4mfbMqc3bWFD-tladXa2xU9OZNSIUqwkE_pV1mCijhm_s0...
Effective URL: https://www.jfshouston.org/forms/counseling-request
Submission: On February 01 via api from US — Scanned from DE
Effective URL: https://www.jfshouston.org/forms/counseling-request
Submission: On February 01 via api from US — Scanned from DE
Form analysis 4 forms found in the DOM
/search
<form action="/search" id="search" class="search w-form">
<div class="img-search"></div><input type="search" spellcheck="false" class="search-input w-input" maxlength="256" name="query" aria-label="search" placeholder="Search…" id="search-nav" input-type="search" required=""><input type="submit"
value="Search" class="search-button w-button">
</form>/search
<form action="/search" id="search" aria-label="search" class="search w-form">
<div class="img-search"></div><input type="search" class="search-input w-input" maxlength="256" name="query" placeholder="" id="search" required=""><input type="submit" value="Search" class="search-button w-button">
</form>POST https://jewishfamilyservicesajivu.formstack.com/forms/index.php
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<div id="resumeConfirm" style="display:none;">Are you sure you want to leave this form and resume later?</div>
<div id="resumeConfirmPassword" style="display: none;">Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.</div>
<div id="saveAndResume" style="display: none;">Save and Resume Later</div>
<div id="saveResumeProcess" style="display: none;">Save and get link</div>
<div id="fileTypeAlert" style="display:none;">You must upload one of the following file types for the selected field:</div>
<div id="embedError" style="display:none;">There was an error displaying the form. Please copy and paste the embed code again.</div>
<div id="applyDiscountButton" style="display:none;">Apply Discount</div>
<div id="dcmYouSaved" style="display:none;">You saved</div>
<div id="dcmWithCode" style="display:none;">with code</div>
<div id="submitButtonText" style="display:none;">Submit Form</div>
<div id="submittingText" style="display:none;">Submitting</div>
<div id="validatingText" style="display:none;">Validating</div>
<div id="autocaptureDisabledText" style="display:none;"></div>
<div id="paymentInitError" style="display:none;">There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.</div>
<div id="checkFieldPrompt" style="display:none;">Please check the field: </div>
<div id="translatedWord-fields" style="display:none;">Fields</div>
<div class="fsPage" id="fsPage4101556-1">
<div id="ReactContainer4101556" style="display:none" class="FsReactContainerInitApp" data-fs-react-app-id="4101556"></div>
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<p><strong><span style="font-size: 24px;">Behavioral and Mental Health Services Request Form</span></strong></p>
<p><span style="font-size: 12px;">JFS Houston is currently offering both telehealth services via our HIPAA compliant online provider (Zoom) and in-person services.</span></p>
</div>
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<div class="fsSubField fsFieldAddress">
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<input data-skip-validation="" data-date-format="M d, Y" type="hidden" id="field100472955Format" name="field100472955Format" value="MDY">
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<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
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<option value="13">13</option>
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<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
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<option value="27">27</option>
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<option value="29">29</option>
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<option value="1908">1908</option>
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<option value="1928">1928</option>
<option value="1929">1929</option>
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<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
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<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
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<option value="2014">2014</option>
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<option value="2018">2018</option>
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<option value="2021">2021</option>
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<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
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<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell122836619" lang="en" fs-field-type="radio" fs-field-validation-name="Race">
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<div class="fieldset-content">
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<label class="fsOptionLabel vertical" for="field122836619_7"><input type="radio" id="field122836619_7" name="field122836619" value="Native Hawaiian or Other Pacific Islander" class="fsField fsRequired vertical"
aria-required="true">Native Hawaiian or Other Pacific Islander</label>
<label class="fsOptionLabel vertical" for="field122836619_8"><input type="radio" id="field122836619_8" name="field122836619" value="White" class="fsField fsRequired vertical" aria-required="true">White</label>
<label class="fsOptionLabel vertical" for="field122836619_9"><input type="radio" id="field122836619_9" name="field122836619" value="Not listed" class="fsField fsRequired vertical" aria-required="true">Not listed</label>
<label class="fsOptionLabel vertical" for="field122836619_10"><input type="radio" id="field122836619_10" name="field122836619" value="Unknown" class="fsField fsRequired vertical" aria-required="true">Unknown</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-11" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100472981" lang="en" fs-field-type="text" fs-field-validation-name="Religion">
<label id="label100472981" class="fsLabel fsRequiredLabel" for="field100472981">Religion<span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field100472981" name="field100472981" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true">
</div>
</div>
<div id="fsRow4101556-12" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100472995" lang="en" fs-field-type="radio" fs-field-validation-name="Client's Sex">
<fieldset role="group" aria-labelledby="fsLegend100472995" id="label100472995">
<legend id="fsLegend100472995" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Client's Sex<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100472995_1"><input type="radio" id="field100472995_1" name="field100472995" value="Male" class="fsField fsRequired vertical" aria-required="true">Male</label>
<label class="fsOptionLabel vertical" for="field100472995_2"><input type="radio" id="field100472995_2" name="field100472995" value="Female" class="fsField fsRequired vertical" aria-required="true">Female</label>
<label class="fsOptionLabel vertical" for="field100472995_3"><input type="radio" id="field100472995_3" name="field100472995" value="Other" class="fsField fsRequired vertical" aria-required="true">Other</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-13" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell122836642" lang="en" fs-field-type="radio" fs-field-validation-name="Client's Gender">
<fieldset role="group" aria-labelledby="fsLegend122836642" id="label122836642">
<legend id="fsLegend122836642" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Client's Gender<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field122836642_1"><input type="radio" id="field122836642_1" name="field122836642" value="Female" class="fsField fsRequired vertical" aria-required="true">Female</label>
<label class="fsOptionLabel vertical" for="field122836642_2"><input type="radio" id="field122836642_2" name="field122836642" value="Male" class="fsField fsRequired vertical" aria-required="true">Male</label>
<label class="fsOptionLabel vertical" for="field122836642_3"><input type="radio" id="field122836642_3" name="field122836642" value="Non-binary (non-conforming)" class="fsField fsRequired vertical" aria-required="true">Non-binary
(non-conforming)</label>
<label class="fsOptionLabel vertical" for="field122836642_4"><input type="radio" id="field122836642_4" name="field122836642" value="Transgender Female" class="fsField fsRequired vertical" aria-required="true">Transgender Female</label>
<label class="fsOptionLabel vertical" for="field122836642_5"><input type="radio" id="field122836642_5" name="field122836642" value="Transgender Male" class="fsField fsRequired vertical" aria-required="true">Transgender Male</label>
<label class="fsOptionLabel vertical" for="field122836642_6"><input type="radio" id="field122836642_6" name="field122836642" value="Not listed/other" class="fsField fsRequired vertical" aria-required="true">Not listed/other</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-14" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473000" lang="en" fs-field-type="radio" fs-field-validation-name="Preferred Pronouns">
<fieldset role="group" aria-labelledby="fsLegend100473000" id="label100473000">
<legend id="fsLegend100473000" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Preferred Pronouns<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473000_1"><input type="radio" id="field100473000_1" name="field100473000" value="He" class="fsField fsRequired vertical" aria-required="true">He</label>
<label class="fsOptionLabel vertical" for="field100473000_2"><input type="radio" id="field100473000_2" name="field100473000" value="She" class="fsField fsRequired vertical" aria-required="true">She</label>
<label class="fsOptionLabel vertical" for="field100473000_3"><input type="radio" id="field100473000_3" name="field100473000" value="They" class="fsField fsRequired vertical" aria-required="true">They</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-15" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell122836680" lang="en" fs-field-type="radio" fs-field-validation-name="United States Veteran ">
<fieldset role="group" aria-labelledby="fsLegend122836680" id="label122836680">
<legend id="fsLegend122836680" class="fsLabel fsRequiredLabel fsLabelVertical"><span>United States Veteran <span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field122836680_1"><input type="radio" id="field122836680_1" name="field122836680" value="Civilian" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Civilian</label>
<label class="fsOptionLabel vertical" for="field122836680_2"><input type="radio" id="field122836680_2" name="field122836680" value="Veteran" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Veteran</label>
<label class="fsOptionLabel vertical" for="field122836680_3"><input type="radio" id="field122836680_3" name="field122836680" value="Active Duty" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Active
Duty</label>
<label class="fsOptionLabel vertical" for="field122836680_4"><input type="radio" id="field122836680_4" name="field122836680" value="Widow/Widower of Veteran" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Widow/Widower of Veteran</label>
<label class="fsOptionLabel vertical" for="field122836680_5"><input type="radio" id="field122836680_5" name="field122836680" value="Not Disclosed" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Not
Disclosed</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-16" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell100473002" lang="en" fs-field-type="radio" fs-field-validation-name="Marital Status">
<fieldset role="group" aria-labelledby="fsLegend100473002" id="label100473002">
<legend id="fsLegend100473002" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Marital Status<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel horizontal" for="field100473002_1"><input type="radio" id="field100473002_1" name="field100473002" value="Single" class="fsField fsRequired horizontal" aria-required="true" disabled="disabled">Single</label>
<label class="fsOptionLabel horizontal" for="field100473002_2"><input type="radio" id="field100473002_2" name="field100473002" value="Married" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Married</label>
<label class="fsOptionLabel horizontal" for="field100473002_3"><input type="radio" id="field100473002_3" name="field100473002" value="Widowed" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Widowed</label>
<label class="fsOptionLabel horizontal" for="field100473002_4"><input type="radio" id="field100473002_4" name="field100473002" value="Cohabitating" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Cohabitating</label>
<label class="fsOptionLabel horizontal" for="field100473002_5"><input type="radio" id="field100473002_5" name="field100473002" value="Divorced" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Divorced</label>
<label class="fsOptionLabel horizontal" for="field100473002_6"><input type="radio" id="field100473002_6" name="field100473002" value="Separated" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Separated</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-17" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell106674088" lang="en" fs-field-type="radio" fs-field-validation-name="Parents' Marital Status">
<fieldset role="group" aria-labelledby="fsLegend106674088" id="label106674088">
<legend id="fsLegend106674088" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Parents' Marital Status<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel horizontal" for="field106674088_1"><input type="radio" id="field106674088_1" name="field106674088" value="Biological parents married" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Biological parents married</label>
<label class="fsOptionLabel horizontal" for="field106674088_2"><input type="radio" id="field106674088_2" name="field106674088" value="Biological parents divorced" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Biological parents divorced</label>
<label class="fsOptionLabel horizontal" for="field106674088_3"><input type="radio" id="field106674088_3" name="field106674088" value="Biological parents never married" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Biological parents never married</label>
<label class="fsOptionLabel horizontal" for="field106674088_4"><input type="radio" id="field106674088_4" name="field106674088" value="Cohabitating" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Cohabitating</label>
<label class="fsOptionLabel horizontal" for="field106674088_5"><input type="radio" id="field106674088_5" name="field106674088" value="Widowed" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Widowed</label>
<label class="fsOptionLabel horizontal" for="field106674088_6"><input type="radio" id="field106674088_6" name="field106674088" value="Foster parent(s)" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Foster parent(s)</label>
<label class="fsOptionLabel horizontal" for="field106674088_7"><input type="radio" id="field106674088_7" name="field106674088" value="Adoptive parent(s)" class="fsField fsRequired horizontal" aria-required="true"
disabled="disabled">Adoptive parent(s)</label>
<div class="horizontal">
<label class="fsOptionLabel horizontal" for="field106674088_other"><input type="radio" id="field106674088_other" name="field106674088" value="Other" class="fsField fsRequired" aria-required="true" disabled="disabled">Other:</label>
<input type="text" id="field106674088_othervalue" name="field106674088_other" size="15" class="fsOtherField" aria-required="true" disabled=""><label class="fsHiddenLabel" style="display: none;" for="field106674088_othervalue">Other
Value</label>
</div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-18" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473005" lang="en" fs-field-type="radio" fs-field-validation-name="Primary Language">
<fieldset role="group" aria-labelledby="fsLegend100473005" id="label100473005">
<legend id="fsLegend100473005" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Primary Language<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473005_1"><input type="radio" id="field100473005_1" name="field100473005" value="English" class="fsField fsRequired vertical" aria-required="true">English</label>
<label class="fsOptionLabel vertical" for="field100473005_2"><input type="radio" id="field100473005_2" name="field100473005" value="Spanish" class="fsField fsRequired vertical" aria-required="true">Spanish</label>
<div class="vertical fs-clear">
<label class="fsOptionLabel vertical" for="field100473005_other"><input type="radio" id="field100473005_other" name="field100473005" value="Other" class="fsField fsRequired" aria-required="true">Other:</label>
<input type="text" id="field100473005_othervalue" name="field100473005_other" size="15" class="fsOtherField" aria-required="true"><label class="fsHiddenLabel" style="display: none;" for="field100473005_othervalue">Other Value</label>
</div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-19" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell106674256" lang="en" fs-field-type="radio" fs-field-validation-name="Primary Language of Parent">
<fieldset role="group" aria-labelledby="fsLegend106674256" id="label106674256">
<legend id="fsLegend106674256" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Primary Language of Parent<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field106674256_1"><input type="radio" id="field106674256_1" name="field106674256" value="English" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">English</label>
<label class="fsOptionLabel vertical" for="field106674256_2"><input type="radio" id="field106674256_2" name="field106674256" value="Spanish" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Spanish</label>
<div class="vertical fs-clear">
<label class="fsOptionLabel vertical" for="field106674256_other"><input type="radio" id="field106674256_other" name="field106674256" value="Other" class="fsField fsRequired" aria-required="true" disabled="disabled">Other:</label>
<input type="text" id="field106674256_othervalue" name="field106674256_other" size="15" class="fsOtherField" aria-required="true" disabled=""><label class="fsHiddenLabel" style="display: none;" for="field106674256_othervalue">Other
Value</label>
</div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-20" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473008" lang="en" fs-field-type="textarea" fs-field-validation-name="What are you seeking counseling for? ">
<label id="label100473008" class="fsLabel fsRequiredLabel" for="field100473008">What are you seeking counseling for? <span class="fsRequiredMarker">*</span> </label>
<textarea id="field100473008" class="fsField fsRequired " name="field100473008" rows="10" cols="50" required="" aria-required="true"></textarea>
</div>
</div>
<div id="fsRow4101556-21" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell134542603" lang="en" fs-field-type="checkbox"
fs-field-validation-name="I am aware that if I am experiencing a life-threating emergency, I will call 988 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).">
<fieldset role="group" aria-labelledby="fsLegend134542603" id="label134542603">
<legend id="fsLegend134542603" class="fsLabel fsRequiredLabel fsLabelVertical"><span>I am aware that if I am experiencing a life-threating emergency, I will call 988 or the National Suicide Prevention Lifeline at 1-800-273-TALK
(8255).<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field134542603_1"><input type="checkbox" id="field134542603_1" name="field134542603[]" value="Yes" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Yes</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-22" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell137310502" lang="en" fs-field-type="checkbox"
fs-field-validation-name="I am aware that if my child is experiencing a life-threating emergency, I will call 988 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). ">
<fieldset role="group" aria-labelledby="fsLegend137310502" id="label137310502">
<legend id="fsLegend137310502" class="fsLabel fsRequiredLabel fsLabelVertical"><span>I am aware that if my child is experiencing a life-threating emergency, I will call 988 or the National Suicide Prevention Lifeline at 1-800-273-TALK
(8255). <span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field137310502_1"><input type="checkbox" id="field137310502_1" name="field137310502[]" value="Yes" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Yes</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-23" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473011" lang="en" fs-field-type="radio" fs-field-validation-name="Do you currently receive any other mental health services? ">
<fieldset role="group" aria-labelledby="fsLegend100473011" id="label100473011">
<legend id="fsLegend100473011" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Do you currently receive any other mental health services? <span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473011_1"><input type="radio" id="field100473011_1" name="field100473011" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field100473011_2"><input type="radio" id="field100473011_2" name="field100473011" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-24" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell100473472" lang="en" fs-field-type="text" fs-field-validation-name="What kind?">
<label id="label100473472" class="fsLabel fsRequiredLabel" for="field100473472">What kind?<span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field100473472" name="field100473472" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true" disabled="disabled">
</div>
</div>
<div id="fsRow4101556-25" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell100473482" lang="en" fs-field-type="text" fs-field-validation-name="Any diagnosis? ">
<label id="label100473482" class="fsLabel fsRequiredLabel" for="field100473482">Any diagnosis? <span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field100473482" name="field100473482" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true" disabled="disabled">
</div>
</div>
<div id="fsRow4101556-26" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473556" lang="en" fs-field-type="radio" fs-field-validation-name="Have you received mental health services in the past?">
<fieldset role="group" aria-labelledby="fsLegend100473556" id="label100473556">
<legend id="fsLegend100473556" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Have you received mental health services in the past?<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473556_1"><input type="radio" id="field100473556_1" name="field100473556" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field100473556_2"><input type="radio" id="field100473556_2" name="field100473556" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-27" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell100473566" lang="en" fs-field-type="text" fs-field-validation-name="Elaborate: ">
<label id="label100473566" class="fsLabel fsRequiredLabel" for="field100473566">Elaborate: <span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field100473566" name="field100473566" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true" disabled="disabled">
</div>
</div>
<div id="fsRow4101556-28" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell125954367" lang="en" fs-field-type="radio"
fs-field-validation-name="In the last 30 days, have you been hospitalized for mental health reasons or attended an IOP/PHP program?">
<fieldset role="group" aria-labelledby="fsLegend125954367" id="label125954367">
<legend id="fsLegend125954367" class="fsLabel fsRequiredLabel fsLabelVertical"><span>In the last 30 days, have you been hospitalized for mental health reasons or attended an IOP/PHP program?<span class="fsRequiredMarker">*</span></span>
</legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field125954367_1"><input type="radio" id="field125954367_1" name="field125954367" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field125954367_2"><input type="radio" id="field125954367_2" name="field125954367" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-29" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell125954471" lang="en" fs-field-type="text" fs-field-validation-name="Name of hospital/program: ">
<label id="label125954471" class="fsLabel" for="field125954471">Name of hospital/program: </label>
<input type="text" id="field125954471" name="field125954471" size="50" value="" class="fsField fsFormatText " disabled="disabled">
</div>
</div>
<div id="fsRow4101556-30" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell125954473" lang="en" fs-field-type="datetime" fs-field-validation-name="Date of discharge: ">
<fieldset role="group" aria-labelledby="fsLegend125954473" id="label125954473">
<legend id="fsLegend125954473" class="fsLabel fsLabelVertical"><span>Date of discharge: </span></legend>
<div class="fieldset-content">
<!-- Used to pull in url for jquery -->
<span aria-hidden="true" style="display:none;" id="fsCalendar125954473ImageUrl">https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png</span>
<input data-skip-validation="" data-date-format="m/d/YY" type="hidden" id="field125954473Format" name="field125954473Format" value="MDY" disabled="">
<div class="hidden"><label for="field125954473M">Month</label></div>
<select id="field125954473M" name="field125954473M" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<div class="hidden"><label for="field125954473D">Day</label></div>
<select id="field125954473D" name="field125954473D" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<div class="hidden"><label for="field125954473Y">Year</label></div>
<select id="field125954473Y" name="field125954473Y" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
</select>
<input data-skip-validation="" type="text" id="fsCalendar125954473Link" class="fsCalendarPickerLink hasDatepicker" style="display:none;" aria-hidden="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png" alt="Select Date" title="Select Date" aria-hidden="true">
<div id="fsCalendar125954473" class="fsCalendar" style=" position:absolute"></div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-31" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473583" lang="en" fs-field-type="radio"
fs-field-validation-name="Any current legal issues we should know about? (divorce, child custody, DWI, assault, etc.) ">
<fieldset role="group" aria-labelledby="fsLegend100473583" id="label100473583">
<legend id="fsLegend100473583" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Any current legal issues we should know about? (divorce, child custody, DWI, assault, etc.) <span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473583_1"><input type="radio" id="field100473583_1" name="field100473583" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field100473583_2"><input type="radio" id="field100473583_2" name="field100473583" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-32" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell100473631" lang="en" fs-field-type="checkbox"
fs-field-validation-name="Select all issues that client/clients' caregivers have experienced:">
<fieldset role="group" aria-labelledby="fsLegend100473631" id="label100473631">
<legend id="fsLegend100473631" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Select all issues that client/clients' caregivers have experienced:<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473631_1"><input type="checkbox" id="field100473631_1" name="field100473631[]" value="Divorce" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Divorce</label>
<label class="fsOptionLabel vertical" for="field100473631_2"><input type="checkbox" id="field100473631_2" name="field100473631[]" value="Child custody" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Child
custody</label>
<label class="fsOptionLabel vertical" for="field100473631_3"><input type="checkbox" id="field100473631_3" name="field100473631[]" value="DWI" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">DWI</label>
<label class="fsOptionLabel vertical" for="field100473631_4"><input type="checkbox" id="field100473631_4" name="field100473631[]" value="Assault" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Assault</label>
<div class="vertical fs-clear">
<label class="fsOptionLabel vertical" style="margin-right: 5px;" for="field100473631_other"><input type="checkbox" id="field100473631_other" name="field100473631[]" value="Other" class="fsField fsRequired" aria-required="true"
disabled="disabled">Other:</label>
<input type="text" id="field100473631_othervalue" name="field100473631_other" size="15" class="fsOtherField" aria-required="true" disabled=""><label class="hidden" for="field100473631_othervalue">Other Value</label>
</div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-33" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473653" lang="en" fs-field-type="radio" fs-field-validation-name="Any safety concerns (restraining orders)?">
<fieldset role="group" aria-labelledby="fsLegend100473653" id="label100473653">
<legend id="fsLegend100473653" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Any safety concerns (restraining orders)?<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473653_1"><input type="radio" id="field100473653_1" name="field100473653" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field100473653_2"><input type="radio" id="field100473653_2" name="field100473653" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-34" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell100473689" lang="en" fs-field-type="text" fs-field-validation-name="What kind? What court? ">
<label id="label100473689" class="fsLabel fsRequiredLabel" for="field100473689">What kind? What court? <span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field100473689" name="field100473689" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true" disabled="disabled">
</div>
</div>
<div id="fsRow4101556-35" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473823" lang="en" fs-field-type="radio" fs-field-validation-name="Any current medical issues that are important for us to know about?">
<fieldset role="group" aria-labelledby="fsLegend100473823" id="label100473823">
<legend id="fsLegend100473823" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Any current medical issues that are important for us to know about?<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473823_1"><input type="radio" id="field100473823_1" name="field100473823" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field100473823_2"><input type="radio" id="field100473823_2" name="field100473823" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-36" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell100473831" lang="en" fs-field-type="text" fs-field-validation-name="What kind? ">
<label id="label100473831" class="fsLabel fsRequiredLabel" for="field100473831">What kind? <span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field100473831" name="field100473831" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true" disabled="disabled">
</div>
</div>
<div id="fsRow4101556-37" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473895" lang="en" fs-field-type="radio" fs-field-validation-name="Did you flood in 2017?">
<fieldset role="group" aria-labelledby="fsLegend100473895" id="label100473895">
<legend id="fsLegend100473895" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Did you flood in 2017?<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473895_1"><input type="radio" id="field100473895_1" name="field100473895" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field100473895_2"><input type="radio" id="field100473895_2" name="field100473895" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-38" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473903" lang="en" fs-field-type="radio" fs-field-validation-name="Are you referred by your EAP? ">
<fieldset role="group" aria-labelledby="fsLegend100473903" id="label100473903">
<legend id="fsLegend100473903" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Are you referred by your EAP? <span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473903_1"><input type="radio" id="field100473903_1" name="field100473903" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field100473903_2"><input type="radio" id="field100473903_2" name="field100473903" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-39" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100473968" lang="en" fs-field-type="radio" fs-field-validation-name="Are you new to JFS Houston? ">
<fieldset role="group" aria-labelledby="fsLegend100473968" id="label100473968">
<legend id="fsLegend100473968" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Are you new to JFS Houston? <span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473968_1"><input type="radio" id="field100473968_1" name="field100473968" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field100473968_2"><input type="radio" id="field100473968_2" name="field100473968" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-40" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell100473975" lang="en" fs-field-type="checkbox" fs-field-validation-name="Other JFS services used:">
<fieldset role="group" aria-labelledby="fsLegend100473975" id="label100473975">
<legend id="fsLegend100473975" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Other JFS services used:<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100473975_1"><input type="checkbox" id="field100473975_1" name="field100473975[]" value="Senior Services" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Senior Services</label>
<label class="fsOptionLabel vertical" for="field100473975_2"><input type="checkbox" id="field100473975_2" name="field100473975[]" value="Financial Aid" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Financial Aid</label>
<label class="fsOptionLabel vertical" for="field100473975_3"><input type="checkbox" id="field100473975_3" name="field100473975[]" value="Employment" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Employment</label>
<label class="fsOptionLabel vertical" for="field100473975_4"><input type="checkbox" id="field100473975_4" name="field100473975[]" value="Family & Counseling" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Family & Counseling</label>
<label class="fsOptionLabel vertical" for="field100473975_5"><input type="checkbox" id="field100473975_5" name="field100473975[]" value="Celebration Company" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Celebration Company</label>
<label class="fsOptionLabel vertical" for="field100473975_6"><input type="checkbox" id="field100473975_6" name="field100473975[]" value="Disaster Services" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Disaster Services</label>
<label class="fsOptionLabel vertical" for="field100473975_7"><input type="checkbox" id="field100473975_7" name="field100473975[]" value="Volunteering" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Volunteering</label>
<div class="vertical fs-clear">
<label class="fsOptionLabel vertical" style="margin-right: 5px;" for="field100473975_other"><input type="checkbox" id="field100473975_other" name="field100473975[]" value="Other" class="fsField fsRequired" aria-required="true"
disabled="disabled">Other:</label>
<input type="text" id="field100473975_othervalue" name="field100473975_other" size="15" class="fsOtherField" aria-required="true" disabled=""><label class="hidden" for="field100473975_othervalue">Other Value</label>
</div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-41" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474053" lang="en" fs-field-type="radio" fs-field-validation-name="Are you new to counseling services at JFS?">
<fieldset role="group" aria-labelledby="fsLegend100474053" id="label100474053">
<legend id="fsLegend100474053" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Are you new to counseling services at JFS?<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100474053_1"><input type="radio" id="field100474053_1" name="field100474053" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field100474053_2"><input type="radio" id="field100474053_2" name="field100474053" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-42" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474119" lang="en" fs-field-type="text" fs-field-validation-name="Best days and times for appointments (no weekend availability):">
<label id="label100474119" class="fsLabel fsRequiredLabel" for="field100474119">Best days and times for appointments (no weekend availability):<span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field100474119" name="field100474119" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true">
</div>
</div>
<div id="fsRow4101556-43" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell127585987" lang="en" fs-field-type="radio" fs-field-validation-name="I prefer:">
<fieldset role="group" aria-labelledby="fsLegend127585987" id="label127585987">
<legend id="fsLegend127585987" class="fsLabel fsRequiredLabel fsLabelVertical"><span>I prefer:<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field127585987_1"><input type="radio" id="field127585987_1" name="field127585987" value="In person session" class="fsField fsRequired vertical" aria-required="true">In person session</label>
<label class="fsOptionLabel vertical" for="field127585987_2"><input type="radio" id="field127585987_2" name="field127585987" value="Telehealth sessions" class="fsField fsRequired vertical" aria-required="true">Telehealth
sessions</label>
<label class="fsOptionLabel vertical" for="field127585987_3"><input type="radio" id="field127585987_3" name="field127585987" value="Open to both" class="fsField fsRequired vertical" aria-required="true">Open to both</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-44" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474127" lang="en" fs-field-type="text" fs-field-validation-name="Who referred you to us: ">
<label id="label100474127" class="fsLabel" for="field100474127">Who referred you to us: </label>
<input type="text" id="field100474127" name="field100474127" size="50" value="" class="fsField fsFormatText ">
</div>
</div>
<div id="fsRow4101556-45" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell114081603" lang="en" fs-field-type="file"
fs-field-validation-name="Please upload image of your ID (for children, upload ID of primary insurance holder)">
<fieldset role="group" aria-labelledby="fsLegend114081603" id="label114081603">
<legend id="fsLegend114081603" class="fsLabel fsLabelVertical"><span>Please upload image of your ID (for children, upload ID of primary insurance holder)</span></legend>
<div class="fieldset-content">
<input type="file" style="display: none" id="field114081603" name="field114081603" size="30"
class="fsField fsUpload uploadTypes-jpg,jpeg,gif,png,bmp,tif,psd,pdf,doc,docx,csv,xls,xlsx,txt,mp3,mp4,aac,wav,au,wmv,avi,mpg,mpeg,zip,gz,rar,z,tgz,tar,sitx">
<input type="button" class="fsFileUploadButton" id="field114081603UploadButton" aria-controls="field114081603" value="Choose File">
<input type="button" class="fsFileUploadButton" id="field114081603DeleteButton" aria-controls="field114081603" value="Remove File">
<span class="fsFileUploadName" id="field114081603FileName">No File Chosen</span>
<div class="showMobile">File uploads may not work on some mobile devices.</div>
<script>
(function() {
var filename = document.getElementById('field114081603FileName').innerHTML
function fileUploadClick() {
var field = document.getElementById('field114081603');
field.click();
}
function fileDelete() {
document.getElementById('field114081603').value = '';
document.getElementById('field114081603FileName').innerHTML = filename;
}
function onFileChange(event) {
if (!event.target.files || !event.target.files.length) {
return;
}
var file = event.target.files[0];
var name = document.getElementById('field114081603FileName');
name.innerHTML = file.name;
}
var button = document.getElementById('field114081603UploadButton');
button.addEventListener('click', fileUploadClick);
var field = document.getElementById('field114081603');
field.addEventListener('change', onFileChange);
var buttonDelete = document.getElementById('field114081603DeleteButton');
buttonDelete.addEventListener('click', fileDelete);
})()
</script>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-46" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474187" lang="en" fs-field-type="richtext" fs-field-validation-name="">
<p><strong><span style="font-size: 24px;">Payment Information</span></strong></p>
</div>
</div>
<div id="fsRow4101556-47" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474162" lang="en" fs-field-type="radio" fs-field-validation-name="Please select one of the following: ">
<fieldset role="group" aria-labelledby="fsLegend100474162" id="label100474162">
<legend id="fsLegend100474162" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Please select one of the following: <span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100474162_1"><input type="radio" id="field100474162_1" name="field100474162" value="I HAVE health insurance" class="fsField fsRequired vertical" aria-required="true">I HAVE health
insurance</label>
<label class="fsOptionLabel vertical" for="field100474162_2"><input type="radio" id="field100474162_2" name="field100474162" value="I do NOT have health insurance" class="fsField fsRequired vertical" aria-required="true">I do NOT have
health insurance</label>
<label class="fsOptionLabel vertical" for="field100474162_3"><input type="radio" id="field100474162_3" name="field100474162" value="I choose not to use my insurance and I agree to pay full price for my services"
class="fsField fsRequired vertical" aria-required="true">I choose not to use my insurance and I agree to pay full price for my services</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-48" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121876415" lang="en" fs-field-type="radio"
fs-field-validation-name="I am willing to see a clinical Intern who is under supervision for a reduced fee and a shorter wait time.">
<fieldset role="group" aria-labelledby="fsLegend121876415" id="label121876415">
<legend id="fsLegend121876415" class="fsLabel fsRequiredLabel fsLabelVertical"><span>I am willing to see a clinical Intern who is under supervision for a reduced fee and a shorter wait time.<span class="fsRequiredMarker">*</span></span>
</legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field121876415_1"><input type="radio" id="field121876415_1" name="field121876415" value="Yes" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Yes</label>
<label class="fsOptionLabel vertical" for="field121876415_2"><input type="radio" id="field121876415_2" name="field121876415" value="No" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-49" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell121876391" lang="en" fs-field-type="richtext" fs-field-validation-name="">
<p data-automation-id="dyn-item-paragraph-2-input" data-w-id="bef4da01-230f-f881-79b6-6c32d0e54c13" data-wf-id="["bef4da01-230f-f881-79b6-6c32d0e54c13"]"><br></p>
<p data-automation-id="dyn-item-paragraph-2-input" data-w-id="bef4da01-230f-f881-79b6-6c32d0e54c13" data-wf-id="["bef4da01-230f-f881-79b6-6c32d0e54c13"]"><strong data-automation-id="dyn-item-paragraph-2-input"
data-w-id="1f2af014-c5eb-53a3-d046-57fbdcb9ac1b" data-wf-id="["1f2af014-c5eb-53a3-d046-57fbdcb9ac1b"]">Good Faith Estimate </strong></p>
<p data-automation-id="dyn-item-paragraph-2-input" data-w-id="c91093fd-36ab-324e-fbf8-ef02a95f40c4" data-wf-id="["c91093fd-36ab-324e-fbf8-ef02a95f40c4"]">If you don't have health insurance or are not using your insurance to cover
your cost of your services, you have the right to receive a “Good Faith Estimate” explaining how much your services will cost before services are provided. </p>
<ul>
<li>You have the right to receive a Good Faith Estimate for the total expected cost of any services upon request or when scheduling such services within a designated timeframe. </li>
<li>You have the right to dispute the bill if it is at least $400 more than your Good Faith Estimate. </li>
</ul>
<p data-automation-id="dyn-item-paragraph-2-input" data-w-id="5b070d6e-03fd-38f7-9ef1-ca3e1f0e532a" data-wf-id="["5b070d6e-03fd-38f7-9ef1-ca3e1f0e532a"]">For questions or more information about your right to a Good Faith Estimate,
visit
<a data-automation-id="dyn-item-paragraph-2-input" data-w-id="94ce1e40-50a0-ff10-54db-5af90c57fbf5" data-wf-id="["94ce1e40-50a0-ff10-54db-5af90c57fbf5"]" href="http://www.cms.gov/nosurprises/consumers" target="_blank">www.cms.gov/nosurprises/consumers</a>,
email<a data-automation-id="dyn-item-paragraph-2-input" data-w-id="68c1e61d-fb9e-9a31-8893-89fb57060b6f" data-wf-id="["68c1e61d-fb9e-9a31-8893-89fb57060b6f"]" href="mailto:FederalPPDRQuestions@cms.hhs.gov"> FederalPPDRQuestions@cms.hhs.gov</a>,
or call <a data-automation-id="dyn-item-paragraph-2-input" data-w-id="b9662817-8867-b610-df26-400902274991" data-wf-id="["b9662817-8867-b610-df26-400902274991"]" href="tel:1-800-985-3059.">1- 800-985-3059.</a> </p>
</div>
</div>
<div id="fsRow4101556-50" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell121876566" lang="en" fs-field-type="richtext" fs-field-validation-name="">
<p><span style="font-size: 24px;">Financial Information </span></p>
<p><br></p>
<p>We collect financial information to determine the fee which is based on a sliding scale. It is determined by your household income and number of people living in your household.</p>
</div>
</div>
<div id="fsRow4101556-51" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell121876595" lang="en" fs-field-type="text" fs-field-validation-name="Monthly Income">
<label id="label121876595" class="fsLabel fsRequiredLabel" for="field121876595">Monthly Income<span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field121876595" name="field121876595" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true">
</div>
</div>
<div id="fsRow4101556-52" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell106673958" lang="en" fs-field-type="number" fs-field-validation-name="Number of people living in your household (include all adults and children)">
<label id="label106673958" class="fsLabel fsRequiredLabel" for="field106673958">Number of people living in your household (include all adults and children)<span class="fsRequiredMarker">*</span> </label>
<input type="number" step="any" id="field106673958" name="field106673958" required="" class="fsField fsFormatNumber fsNumberDecimals-0 fsRequired" aria-required="true">
<script>
//This script is to address some quirkiness of Safari where commas are interchangeable with decimal points on number fields.
//Normal attempts to restrict the comma such as our own validation or .replace(",", "") results in the value of the field being removed entirely.
//Below the keypress itself is being blocked as a workaround to keep our value.
document.getElementById("field106673958").addEventListener("keydown", function blockComma(e) {
if (e.code === 'Comma') {
e.preventDefault();
}
})
</script>
</div>
</div>
<div id="fsRow4101556-53" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991332" lang="en" fs-field-type="name" fs-field-validation-name="Name">
<span id="label121991332" class="fsLabel">Name</span>
<div class="fsSubFieldGroup">
<div class="fsSubField fsNameFirst">
<input type="text" id="field121991332-first" name="field121991332-first" size="20" aria-label="First Name" value="" class="fsField fsFieldName" disabled="disabled">
<label class="fsSupporting" for="field121991332-first">First Name</label>
</div>
<div class="fsSubField fsNameLast">
<input type="text" id="field121991332-last" name="field121991332-last" size="20" aria-label="Last Name" value="" class="fsField fsFieldName" disabled="disabled">
<label class="fsSupporting" for="field121991332-last">Last Name</label>
</div>
</div>
<div class="clear"></div>
</div>
</div>
<div id="fsRow4101556-54" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991336" lang="en" fs-field-type="text" fs-field-validation-name="Relationship">
<label id="label121991336" class="fsLabel" for="field121991336">Relationship </label>
<input type="text" id="field121991336" name="field121991336" size="50" value="" class="fsField fsFormatText " disabled="disabled">
</div>
</div>
<div id="fsRow4101556-55" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991337" lang="en" fs-field-type="datetime" fs-field-validation-name="Birthdate">
<fieldset role="group" aria-labelledby="fsLegend121991337" id="label121991337">
<legend id="fsLegend121991337" class="fsLabel fsLabelVertical"><span>Birthdate</span></legend>
<div class="fieldset-content">
<!-- Used to pull in url for jquery -->
<span aria-hidden="true" style="display:none;" id="fsCalendar121991337ImageUrl">https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png</span>
<input data-skip-validation="" data-date-format="m/d/YY" type="hidden" id="field121991337Format" name="field121991337Format" value="MDY" disabled="">
<div class="hidden"><label for="field121991337M">Month</label></div>
<select id="field121991337M" name="field121991337M" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<div class="hidden"><label for="field121991337D">Day</label></div>
<select id="field121991337D" name="field121991337D" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<div class="hidden"><label for="field121991337Y">Year</label></div>
<select id="field121991337Y" name="field121991337Y" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="1923">1923</option>
<option value="1924">1924</option>
<option value="1925">1925</option>
<option value="1926">1926</option>
<option value="1927">1927</option>
<option value="1928">1928</option>
<option value="1929">1929</option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
</select>
<input data-skip-validation="" type="text" id="fsCalendar121991337Link" class="fsCalendarPickerLink hasDatepicker" style="display:none;" aria-hidden="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png" alt="Select Date" title="Select Date" aria-hidden="true">
<div id="fsCalendar121991337" class="fsCalendar" style=" position:absolute"></div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-56" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991361" lang="en" fs-field-type="name" fs-field-validation-name="Name of Person 2">
<span id="label121991361" class="fsLabel">Name of Person 2</span>
<div class="fsSubFieldGroup">
<div class="fsSubField fsNameFirst">
<input type="text" id="field121991361-first" name="field121991361-first" size="20" aria-label="First Name" value="" class="fsField fsFieldName" disabled="disabled">
<label class="fsSupporting" for="field121991361-first">First Name</label>
</div>
<div class="fsSubField fsNameLast">
<input type="text" id="field121991361-last" name="field121991361-last" size="20" aria-label="Last Name" value="" class="fsField fsFieldName" disabled="disabled">
<label class="fsSupporting" for="field121991361-last">Last Name</label>
</div>
</div>
<div class="clear"></div>
</div>
</div>
<div id="fsRow4101556-57" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991362" lang="en" fs-field-type="text" fs-field-validation-name="Relationship with Person 2">
<label id="label121991362" class="fsLabel" for="field121991362">Relationship with Person 2 </label>
<input type="text" id="field121991362" name="field121991362" size="50" value="" class="fsField fsFormatText " disabled="disabled">
</div>
</div>
<div id="fsRow4101556-58" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991364" lang="en" fs-field-type="datetime" fs-field-validation-name="Birthdate of Person 2">
<fieldset role="group" aria-labelledby="fsLegend121991364" id="label121991364">
<legend id="fsLegend121991364" class="fsLabel fsLabelVertical"><span>Birthdate of Person 2</span></legend>
<div class="fieldset-content">
<!-- Used to pull in url for jquery -->
<span aria-hidden="true" style="display:none;" id="fsCalendar121991364ImageUrl">https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png</span>
<input data-skip-validation="" data-date-format="m/d/YY" type="hidden" id="field121991364Format" name="field121991364Format" value="MDY" disabled="">
<div class="hidden"><label for="field121991364M">Month</label></div>
<select id="field121991364M" name="field121991364M" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<div class="hidden"><label for="field121991364D">Day</label></div>
<select id="field121991364D" name="field121991364D" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<div class="hidden"><label for="field121991364Y">Year</label></div>
<select id="field121991364Y" name="field121991364Y" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="1923">1923</option>
<option value="1924">1924</option>
<option value="1925">1925</option>
<option value="1926">1926</option>
<option value="1927">1927</option>
<option value="1928">1928</option>
<option value="1929">1929</option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
</select>
<input data-skip-validation="" type="text" id="fsCalendar121991364Link" class="fsCalendarPickerLink hasDatepicker" style="display:none;" aria-hidden="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png" alt="Select Date" title="Select Date" aria-hidden="true">
<div id="fsCalendar121991364" class="fsCalendar" style=" position:absolute"></div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-59" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991412" lang="en" fs-field-type="name" fs-field-validation-name="Name of Person 3">
<span id="label121991412" class="fsLabel">Name of Person 3</span>
<div class="fsSubFieldGroup">
<div class="fsSubField fsNameFirst">
<input type="text" id="field121991412-first" name="field121991412-first" size="20" aria-label="First Name" value="" class="fsField fsFieldName" disabled="disabled">
<label class="fsSupporting" for="field121991412-first">First Name</label>
</div>
<div class="fsSubField fsNameLast">
<input type="text" id="field121991412-last" name="field121991412-last" size="20" aria-label="Last Name" value="" class="fsField fsFieldName" disabled="disabled">
<label class="fsSupporting" for="field121991412-last">Last Name</label>
</div>
</div>
<div class="clear"></div>
</div>
</div>
<div id="fsRow4101556-60" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991638" lang="en" fs-field-type="text" fs-field-validation-name="Relationship with Person 3">
<label id="label121991638" class="fsLabel" for="field121991638">Relationship with Person 3 </label>
<input type="text" id="field121991638" name="field121991638" size="50" value="" class="fsField fsFormatText " disabled="disabled">
</div>
</div>
<div id="fsRow4101556-61" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991417" lang="en" fs-field-type="datetime" fs-field-validation-name="Birthdate of Person 3">
<fieldset role="group" aria-labelledby="fsLegend121991417" id="label121991417">
<legend id="fsLegend121991417" class="fsLabel fsLabelVertical"><span>Birthdate of Person 3</span></legend>
<div class="fieldset-content">
<!-- Used to pull in url for jquery -->
<span aria-hidden="true" style="display:none;" id="fsCalendar121991417ImageUrl">https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png</span>
<input data-skip-validation="" data-date-format="m/d/YY" type="hidden" id="field121991417Format" name="field121991417Format" value="MDY" disabled="">
<div class="hidden"><label for="field121991417M">Month</label></div>
<select id="field121991417M" name="field121991417M" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<div class="hidden"><label for="field121991417D">Day</label></div>
<select id="field121991417D" name="field121991417D" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<div class="hidden"><label for="field121991417Y">Year</label></div>
<select id="field121991417Y" name="field121991417Y" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="1923">1923</option>
<option value="1924">1924</option>
<option value="1925">1925</option>
<option value="1926">1926</option>
<option value="1927">1927</option>
<option value="1928">1928</option>
<option value="1929">1929</option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
</select>
<input data-skip-validation="" type="text" id="fsCalendar121991417Link" class="fsCalendarPickerLink hasDatepicker" style="display:none;" aria-hidden="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png" alt="Select Date" title="Select Date" aria-hidden="true">
<div id="fsCalendar121991417" class="fsCalendar" style=" position:absolute"></div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-62" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991461" lang="en" fs-field-type="name" fs-field-validation-name="Name of Person 4">
<span id="label121991461" class="fsLabel">Name of Person 4</span>
<div class="fsSubFieldGroup">
<div class="fsSubField fsNameFirst">
<input type="text" id="field121991461-first" name="field121991461-first" size="20" aria-label="First Name" value="" class="fsField fsFieldName" disabled="disabled">
<label class="fsSupporting" for="field121991461-first">First Name</label>
</div>
<div class="fsSubField fsNameLast">
<input type="text" id="field121991461-last" name="field121991461-last" size="20" aria-label="Last Name" value="" class="fsField fsFieldName" disabled="disabled">
<label class="fsSupporting" for="field121991461-last">Last Name</label>
</div>
</div>
<div class="clear"></div>
</div>
</div>
<div id="fsRow4101556-63" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991415" lang="en" fs-field-type="text" fs-field-validation-name="Relationship with Person 4">
<label id="label121991415" class="fsLabel" for="field121991415">Relationship with Person 4 </label>
<input type="text" id="field121991415" name="field121991415" size="50" value="" class="fsField fsFormatText " disabled="disabled">
</div>
</div>
<div id="fsRow4101556-64" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991505" lang="en" fs-field-type="datetime" fs-field-validation-name="Birthdate of Person 4">
<fieldset role="group" aria-labelledby="fsLegend121991505" id="label121991505">
<legend id="fsLegend121991505" class="fsLabel fsLabelVertical"><span>Birthdate of Person 4</span></legend>
<div class="fieldset-content">
<!-- Used to pull in url for jquery -->
<span aria-hidden="true" style="display:none;" id="fsCalendar121991505ImageUrl">https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png</span>
<input data-skip-validation="" data-date-format="m/d/YY" type="hidden" id="field121991505Format" name="field121991505Format" value="MDY" disabled="">
<div class="hidden"><label for="field121991505M">Month</label></div>
<select id="field121991505M" name="field121991505M" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<div class="hidden"><label for="field121991505D">Day</label></div>
<select id="field121991505D" name="field121991505D" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<div class="hidden"><label for="field121991505Y">Year</label></div>
<select id="field121991505Y" name="field121991505Y" class=" fsField" disabled="disabled">
<option value=""> </option>
<option value="1923">1923</option>
<option value="1924">1924</option>
<option value="1925">1925</option>
<option value="1926">1926</option>
<option value="1927">1927</option>
<option value="1928">1928</option>
<option value="1929">1929</option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
</select>
<input data-skip-validation="" type="text" id="fsCalendar121991505Link" class="fsCalendarPickerLink hasDatepicker" style="display:none;" aria-hidden="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png" alt="Select Date" title="Select Date" aria-hidden="true">
<div id="fsCalendar121991505" class="fsCalendar" style=" position:absolute"></div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-65" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell121991512" lang="en" fs-field-type="textarea"
fs-field-validation-name="Please list names, relationship to you and birthdate of additional people living with you.">
<label id="label121991512" class="fsLabel" for="field121991512">Please list names, relationship to you and birthdate of additional people living with you. </label>
<textarea id="field121991512" class="fsField " name="field121991512" rows="10" cols="50" disabled="disabled"></textarea>
</div>
</div>
<div id="fsRow4101556-66" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell121876733" lang="en" fs-field-type="radio"
fs-field-validation-name="If you have children in your household, are they enrolled in daycare or afterschool care? ">
<fieldset role="group" aria-labelledby="fsLegend121876733" id="label121876733">
<legend id="fsLegend121876733" class="fsLabel fsRequiredLabel fsLabelVertical"><span>If you have children in your household, are they enrolled in daycare or afterschool care? <span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field121876733_1"><input type="radio" id="field121876733_1" name="field121876733" value="Yes" class="fsField fsRequired vertical" aria-required="true">Yes</label>
<label class="fsOptionLabel vertical" for="field121876733_2"><input type="radio" id="field121876733_2" name="field121876733" value="No" class="fsField fsRequired vertical" aria-required="true">No</label>
<label class="fsOptionLabel vertical" for="field121876733_3"><input type="radio" id="field121876733_3" name="field121876733" value="N/A" class="fsField fsRequired vertical" aria-required="true">N/A</label>
</div>
</fieldset>
</div>
</div>
</div>
<div class="fsSection fs1Col fsHidden" id="fsSection100495955">
<div class="fsSectionHeader">
<h2 class="fsSectionHeading">Caregiver Information </h2>
</div>
<div id="fsRow4101556-68" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100495963" lang="en" fs-field-type="name" fs-field-validation-name="Caregiver Name">
<span id="label100495963" class="fsLabel fsRequiredLabel">Caregiver Name<span class="fsRequiredMarker">*</span></span>
<div class="fsSubFieldGroup">
<div class="fsSubField fsNameFirst">
<input type="text" id="field100495963-first" name="field100495963-first" size="20" aria-label="First Name" value="" required="" class="fsField fsFieldName fsRequired" aria-required="true" disabled="disabled">
<label class="fsSupporting fsRequiredLabel" for="field100495963-first">First Name<span class="hidden">*</span></label>
</div>
<div class="fsSubField fsNameLast">
<input type="text" id="field100495963-last" name="field100495963-last" size="20" aria-label="Last Name" value="" required="" class="fsField fsFieldName fsRequired" aria-required="true" disabled="disabled">
<label class="fsSupporting fsRequiredLabel" for="field100495963-last">Last Name<span class="hidden">*</span></label>
</div>
</div>
<div class="clear"></div>
</div>
</div>
<div id="fsRow4101556-69" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100495967" lang="en" fs-field-type="checkbox" fs-field-validation-name="Relationship to Client: ">
<fieldset role="group" aria-labelledby="fsLegend100495967" id="label100495967">
<legend id="fsLegend100495967" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Relationship to Client: <span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100495967_1"><input type="checkbox" id="field100495967_1" name="field100495967[]" value="Legal Guardian" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Legal
Guardian</label>
<label class="fsOptionLabel vertical" for="field100495967_2"><input type="checkbox" id="field100495967_2" name="field100495967[]" value="Power of Attorney" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Power of Attorney</label>
<label class="fsOptionLabel vertical" for="field100495967_3"><input type="checkbox" id="field100495967_3" name="field100495967[]" value="Custodial Parent" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Custodial Parent</label>
<label class="fsOptionLabel vertical" for="field100495967_4"><input type="checkbox" id="field100495967_4" name="field100495967[]" value="Relative" class="fsField fsRequired vertical" aria-required="true"
disabled="disabled">Relative</label>
<div class="vertical fs-clear">
<label class="fsOptionLabel vertical" style="margin-right: 5px;" for="field100495967_other"><input type="checkbox" id="field100495967_other" name="field100495967[]" value="Other" class="fsField fsRequired" aria-required="true"
disabled="disabled">Other:</label>
<input type="text" id="field100495967_othervalue" name="field100495967_other" size="15" class="fsOtherField" aria-required="true" disabled=""><label class="hidden" for="field100495967_othervalue">Other Value</label>
</div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-70" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell100496189" aria-describedby="fsSupporting100496189" lang="en" fs-field-type="radio"
fs-field-validation-name="Do you have signed legal documents? ">
<fieldset role="group" aria-labelledby="fsLegend100496189" id="label100496189">
<legend id="fsLegend100496189" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Do you have signed legal documents? <span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field100496189_1"><input type="radio" id="field100496189_1" name="field100496189" value="Yes" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">Yes</label>
<label class="fsOptionLabel vertical" for="field100496189_2"><input type="radio" id="field100496189_2" name="field100496189" value="No" class="fsField fsRequired vertical" aria-required="true" disabled="disabled">No</label>
<div id="fsSupporting100496189" class="fsSupporting">Please bring copies</div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-71" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100496222" lang="en" fs-field-type="phone" fs-field-validation-name="Caregiver Phone">
<label id="label100496222" class="fsLabel fsRequiredLabel" for="field100496222">Caregiver Phone<span class="fsRequiredMarker">*</span> </label>
<input type="tel" id="field100496222" name="field100496222" size="2" required="" value="" class="fsField fsFormatPhoneUS fsRequired" aria-required="true" disabled="disabled" data-country="US" data-format="national">
</div>
</div>
<div id="fsRow4101556-72" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100496231" lang="en" fs-field-type="email" fs-field-validation-name="Caregiver Email">
<label id="label100496231" class="fsLabel fsRequiredLabel" for="field100496231">Caregiver Email<span class="fsRequiredMarker">*</span> </label>
<input type="email" id="field100496231" name="field100496231" size="50" required="required" value="" class="fsField fsFormatEmail fsRequired" aria-required="true" disabled="disabled">
</div>
</div>
<div id="fsRow4101556-73" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100496258" lang="en" fs-field-type="address" fs-field-validation-name="Caregiver Address">
<span id="label100496258" class="fsLabel fsRequiredLabel">Caregiver Address<span class="fsRequiredMarker">*</span></span>
<div class="fsSubFieldGroup">
<div class="fsSubField fsFieldAddress">
<input type="text" id="field100496258-address" aria-label="Address Line 1" name="field100496258-address" size="50" value="" required="" class="fsField fsFieldAddress fsRequired" aria-required="true" disabled="disabled">
<label class="fsSupporting" for="field100496258-address">Address Line 1</label>
</div>
<div class="fsSubField fsFieldAddress2">
<input type="text" id="field100496258-address2" aria-label="Address Line 2" name="field100496258-address2" size="50" value="" class="fsField fsFieldAddress2" disabled="disabled">
<label class="fsSupporting" for="field100496258-address2">Address Line 2</label>
</div>
<div class="fsSubField fsFieldCity">
<input type="text" id="field100496258-city" name="field100496258-city" size="15" aria-label="City" value="" required="" class="fsField fsFieldCity fsRequired" aria-required="true" disabled="disabled">
<label class="fsSupporting" for="field100496258-city">City</label>
</div>
<div class="fsSubField fsFieldState">
<select id="field100496258-state" aria-label="State" name="field100496258-state" required="" class="fsField fsFieldState fsRequired" aria-required="true" disabled="disabled">
<option value=""> </option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="GU">Guam</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="PR">Puerto Rico</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VI">Virgin Islands (US)</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="AA">Armed Forces (the) Americas</option>
<option value="AE">Armed Forces Europe</option>
<option value="AP">Armed Forces Pacific</option>
<option value="APO">Army Post Office (U.S. Army and U.S. Air Force)</option>
<option value="FPO">Fleet Post Office (U.S. Navy and U.S. Marine Corps)</option>
</select>
<label class="fsSupporting" for="field100496258-state">State</label>
</div>
<div class="fsSubField fsFieldZip">
<input type="text" id="field100496258-zip" aria-label="ZIP Code" name="field100496258-zip" size="6" value="" required="" class="fsField fsFieldZip fsFormatZipUS fsRequired" aria-required="true" disabled="disabled">
<label class="fsSupporting" for="field100496258-zip">ZIP Code</label>
</div>
</div>
<div class="clear"></div>
</div>
</div>
</div>
<div class="fsSection fs1Col fsHidden" id="fsSection100474368">
<div class="fsSectionHeader">
<h2 class="fsSectionHeading">Health Insurance Information</h2>
</div>
<div id="fsRow4101556-75" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474388" lang="en" fs-field-type="text" fs-field-validation-name="Insurance Company Name ">
<label id="label100474388" class="fsLabel fsRequiredLabel" for="field100474388">Insurance Company Name <span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field100474388" name="field100474388" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true" disabled="disabled">
</div>
</div>
<div id="fsRow4101556-76" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474457" lang="en" fs-field-type="name" fs-field-validation-name="Policy Holder Name">
<span id="label100474457" class="fsLabel fsRequiredLabel">Policy Holder Name<span class="fsRequiredMarker">*</span></span>
<div class="fsSubFieldGroup">
<div class="fsSubField fsNameFirst">
<input type="text" id="field100474457-first" name="field100474457-first" size="20" aria-label="First Name" value="" required="" class="fsField fsFieldName fsRequired" aria-required="true" disabled="disabled">
<label class="fsSupporting fsRequiredLabel" for="field100474457-first">First Name<span class="hidden">*</span></label>
</div>
<div class="fsSubField fsNameLast">
<input type="text" id="field100474457-last" name="field100474457-last" size="20" aria-label="Last Name" value="" required="" class="fsField fsFieldName fsRequired" aria-required="true" disabled="disabled">
<label class="fsSupporting fsRequiredLabel" for="field100474457-last">Last Name<span class="hidden">*</span></label>
</div>
</div>
<div class="clear"></div>
</div>
</div>
<div id="fsRow4101556-77" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474462" lang="en" fs-field-type="datetime" fs-field-validation-name="Date of Birth of Policy Holder">
<fieldset role="group" aria-labelledby="fsLegend100474462" id="label100474462">
<legend id="fsLegend100474462" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Date of Birth of Policy Holder<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<!-- Used to pull in url for jquery -->
<span aria-hidden="true" style="display:none;" id="fsCalendar100474462ImageUrl">https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png</span>
<input data-skip-validation="" data-date-format="M d, Y" type="hidden" id="field100474462Format" name="field100474462Format" value="MDY" disabled="">
<div class="hidden"><label for="field100474462M">Month</label></div>
<select id="field100474462M" name="field100474462M" class=" fsField fsRequired" aria-required="true" disabled="disabled">
<option value=""> </option>
<option value="Jan">Jan</option>
<option value="Feb">Feb</option>
<option value="Mar">Mar</option>
<option value="Apr">Apr</option>
<option value="May">May</option>
<option value="Jun">Jun</option>
<option value="Jul">Jul</option>
<option value="Aug">Aug</option>
<option value="Sep">Sep</option>
<option value="Oct">Oct</option>
<option value="Nov">Nov</option>
<option value="Dec">Dec</option>
</select>
<div class="hidden"><label for="field100474462D">Day</label></div>
<select id="field100474462D" name="field100474462D" class=" fsField fsRequired" aria-required="true" disabled="disabled">
<option value=""> </option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<div class="hidden"><label for="field100474462Y">Year</label></div>
<select id="field100474462Y" name="field100474462Y" class=" fsField fsRequired" aria-required="true" disabled="disabled">
<option value=""> </option>
<option value="1903">1903</option>
<option value="1904">1904</option>
<option value="1905">1905</option>
<option value="1906">1906</option>
<option value="1907">1907</option>
<option value="1908">1908</option>
<option value="1909">1909</option>
<option value="1910">1910</option>
<option value="1911">1911</option>
<option value="1912">1912</option>
<option value="1913">1913</option>
<option value="1914">1914</option>
<option value="1915">1915</option>
<option value="1916">1916</option>
<option value="1917">1917</option>
<option value="1918">1918</option>
<option value="1919">1919</option>
<option value="1920">1920</option>
<option value="1921">1921</option>
<option value="1922">1922</option>
<option value="1923">1923</option>
<option value="1924">1924</option>
<option value="1925">1925</option>
<option value="1926">1926</option>
<option value="1927">1927</option>
<option value="1928">1928</option>
<option value="1929">1929</option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
</select>
<input data-skip-validation="" type="text" id="fsCalendar100474462Link" class="fsCalendarPickerLink hasDatepicker" style="display:none;" aria-hidden="true" disabled="disabled"><img class="ui-datepicker-trigger"
src="https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png" alt="Select Date" title="Select Date" aria-hidden="true">
<div id="fsCalendar100474462" class="fsCalendar" style=" position:absolute"></div>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-78" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474482" lang="en" fs-field-type="phone" fs-field-validation-name="Phone Number on the Back of the Card">
<label id="label100474482" class="fsLabel fsRequiredLabel" for="field100474482">Phone Number on the Back of the Card<span class="fsRequiredMarker">*</span> </label>
<input type="tel" id="field100474482" name="field100474482" size="2" required="" value="" class="fsField fsFormatPhoneUS fsRequired" aria-required="true" disabled="disabled" data-country="US" data-format="national">
</div>
</div>
<div id="fsRow4101556-79" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474497" lang="en" fs-field-type="text" fs-field-validation-name="Member ID #">
<label id="label100474497" class="fsLabel fsRequiredLabel" for="field100474497">Member ID #<span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field100474497" name="field100474497" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true" disabled="disabled">
</div>
</div>
<div id="fsRow4101556-80" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell100474544" lang="en" fs-field-type="text" fs-field-validation-name="Group #">
<label id="label100474544" class="fsLabel fsRequiredLabel" for="field100474544">Group #<span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field100474544" name="field100474544" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true" disabled="disabled">
</div>
</div>
<div id="fsRow4101556-81" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell113904509" lang="en" fs-field-type="file" fs-field-validation-name="Please upload image of front of insurance card. ">
<fieldset role="group" aria-labelledby="fsLegend113904509" id="label113904509">
<legend id="fsLegend113904509" class="fsLabel fsLabelVertical"><span>Please upload image of front of insurance card. </span></legend>
<div class="fieldset-content">
<input type="file" style="display: none" id="field113904509" name="field113904509" size="30"
class="fsField fsUpload uploadTypes-jpg,jpeg,gif,png,bmp,tif,psd,pdf,doc,docx,csv,xls,xlsx,txt,mp3,mp4,aac,wav,au,wmv,avi,mpg,mpeg,zip,gz,rar,z,tgz,tar,sitx" disabled="disabled">
<input type="button" class="fsFileUploadButton" id="field113904509UploadButton" aria-controls="field113904509" value="Choose File" disabled="">
<input type="button" class="fsFileUploadButton" id="field113904509DeleteButton" aria-controls="field113904509" value="Remove File" disabled="">
<span class="fsFileUploadName" id="field113904509FileName">No File Chosen</span>
<div class="showMobile">File uploads may not work on some mobile devices.</div>
<script>
(function() {
var filename = document.getElementById('field113904509FileName').innerHTML
function fileUploadClick() {
var field = document.getElementById('field113904509');
field.click();
}
function fileDelete() {
document.getElementById('field113904509').value = '';
document.getElementById('field113904509FileName').innerHTML = filename;
}
function onFileChange(event) {
if (!event.target.files || !event.target.files.length) {
return;
}
var file = event.target.files[0];
var name = document.getElementById('field113904509FileName');
name.innerHTML = file.name;
}
var button = document.getElementById('field113904509UploadButton');
button.addEventListener('click', fileUploadClick);
var field = document.getElementById('field113904509');
field.addEventListener('change', onFileChange);
var buttonDelete = document.getElementById('field113904509DeleteButton');
buttonDelete.addEventListener('click', fileDelete);
})()
</script>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-82" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell113904511" lang="en" fs-field-type="file"
fs-field-validation-name="Please upload image of back of insurance card or secondary insurance if you have one.">
<fieldset role="group" aria-labelledby="fsLegend113904511" id="label113904511">
<legend id="fsLegend113904511" class="fsLabel fsLabelVertical"><span>Please upload image of back of insurance card or secondary insurance if you have one.</span></legend>
<div class="fieldset-content">
<input type="file" style="display: none" id="field113904511" name="field113904511" size="30"
class="fsField fsUpload uploadTypes-jpg,jpeg,gif,png,bmp,tif,psd,pdf,doc,docx,csv,xls,xlsx,txt,mp3,mp4,aac,wav,au,wmv,avi,mpg,mpeg,zip,gz,rar,z,tgz,tar,sitx" disabled="disabled">
<input type="button" class="fsFileUploadButton" id="field113904511UploadButton" aria-controls="field113904511" value="Choose File" disabled="">
<input type="button" class="fsFileUploadButton" id="field113904511DeleteButton" aria-controls="field113904511" value="Remove File" disabled="">
<span class="fsFileUploadName" id="field113904511FileName">No File Chosen</span>
<div class="showMobile">File uploads may not work on some mobile devices.</div>
<script>
(function() {
var filename = document.getElementById('field113904511FileName').innerHTML
function fileUploadClick() {
var field = document.getElementById('field113904511');
field.click();
}
function fileDelete() {
document.getElementById('field113904511').value = '';
document.getElementById('field113904511FileName').innerHTML = filename;
}
function onFileChange(event) {
if (!event.target.files || !event.target.files.length) {
return;
}
var file = event.target.files[0];
var name = document.getElementById('field113904511FileName');
name.innerHTML = file.name;
}
var button = document.getElementById('field113904511UploadButton');
button.addEventListener('click', fileUploadClick);
var field = document.getElementById('field113904511');
field.addEventListener('change', onFileChange);
var buttonDelete = document.getElementById('field113904511DeleteButton');
buttonDelete.addEventListener('click', fileDelete);
})()
</script>
</div>
</fieldset>
</div>
</div>
</div>
<div class="fsSection fs1Col fsHidden" id="fsSection134542439">
<div class="fsSectionHeader">
<h2 class="fsSectionHeading">Free Support Sessions</h2>
<div class="fsSectionText">
<p>JFS offers two free support sessions that can be provided while you are on the waitlist to see a therapist. Support sessions are not therapy and are meant to provide resources and support during the intake process wait time. </p>
</div>
</div>
<div id="fsRow4101556-84" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell134542591" lang="en" fs-field-type="radio" fs-field-validation-name="Are you interested in registering for 2 free support sessions? ">
<fieldset role="group" aria-labelledby="fsLegend134542591" id="label134542591">
<legend id="fsLegend134542591" class="fsLabel fsLabelVertical"><span>Are you interested in registering for 2 free support sessions? </span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field134542591_1"><input type="radio" id="field134542591_1" name="field134542591" value="Yes" class="fsField vertical" disabled="disabled">Yes</label>
<label class="fsOptionLabel vertical" for="field134542591_2"><input type="radio" id="field134542591_2" name="field134542591" value="No" class="fsField vertical" disabled="disabled">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-85" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell134542602" lang="en" fs-field-type="radio"
fs-field-validation-name="I understand that the purpose of the support session is limited to facilitating strength-based support and is not considered mental health counseling or therapy. ">
<fieldset role="group" aria-labelledby="fsLegend134542602" id="label134542602">
<legend id="fsLegend134542602" class="fsLabel fsLabelVertical"><span>I understand that the purpose of the support session is limited to facilitating strength-based support and is not considered mental health counseling or therapy. </span>
</legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field134542602_1"><input type="radio" id="field134542602_1" name="field134542602" value="Yes" class="fsField vertical" disabled="disabled">Yes</label>
<label class="fsOptionLabel vertical" for="field134542602_2"><input type="radio" id="field134542602_2" name="field134542602" value="No" class="fsField vertical" disabled="disabled">No</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-86" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell134542684" lang="en" fs-field-type="checkbox" fs-field-validation-name="What day of the week are you available for your support session?">
<fieldset role="group" aria-labelledby="fsLegend134542684" id="label134542684">
<legend id="fsLegend134542684" class="fsLabel fsLabelVertical"><span>What day of the week are you available for your support session?</span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field134542684_1"><input type="checkbox" id="field134542684_1" name="field134542684[]" value="Monday" class="fsField vertical" disabled="disabled">Monday</label>
<label class="fsOptionLabel vertical" for="field134542684_2"><input type="checkbox" id="field134542684_2" name="field134542684[]" value="Tuesday" class="fsField vertical" disabled="disabled">Tuesday</label>
<label class="fsOptionLabel vertical" for="field134542684_3"><input type="checkbox" id="field134542684_3" name="field134542684[]" value="Wednesday" class="fsField vertical" disabled="disabled">Wednesday</label>
<label class="fsOptionLabel vertical" for="field134542684_4"><input type="checkbox" id="field134542684_4" name="field134542684[]" value="Thursday" class="fsField vertical" disabled="disabled">Thursday</label>
<label class="fsOptionLabel vertical" for="field134542684_5"><input type="checkbox" id="field134542684_5" name="field134542684[]" value="Friday" class="fsField vertical" disabled="disabled">Friday</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-87" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell134542699" lang="en" fs-field-type="checkbox"
fs-field-validation-name="What time of day would you prefer your support session be scheduled?">
<fieldset role="group" aria-labelledby="fsLegend134542699" id="label134542699">
<legend id="fsLegend134542699" class="fsLabel fsLabelVertical"><span>What time of day would you prefer your support session be scheduled?</span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field134542699_1"><input type="checkbox" id="field134542699_1" name="field134542699[]" value="Morning support session" class="fsField vertical" disabled="disabled">Morning support
session</label>
<label class="fsOptionLabel vertical" for="field134542699_2"><input type="checkbox" id="field134542699_2" name="field134542699[]" value="Afternoon support session" class="fsField vertical" disabled="disabled">Afternoon support
session</label>
</div>
</fieldset>
</div>
</div>
<div id="fsRow4101556-88" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell134542708" lang="en" fs-field-type="checkbox" fs-field-validation-name="Would you prefer your session to be: ">
<fieldset role="group" aria-labelledby="fsLegend134542708" id="label134542708">
<legend id="fsLegend134542708" class="fsLabel fsLabelVertical"><span>Would you prefer your session to be: </span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field134542708_1"><input type="checkbox" id="field134542708_1" name="field134542708[]" value="Virtual" class="fsField vertical" disabled="disabled">Virtual</label>
<label class="fsOptionLabel vertical" for="field134542708_2"><input type="checkbox" id="field134542708_2" name="field134542708[]" value="In-person" class="fsField vertical" disabled="disabled">In-person</label>
<label class="fsOptionLabel vertical" for="field134542708_3"><input type="checkbox" id="field134542708_3" name="field134542708[]" value="Either" class="fsField vertical" disabled="disabled">Either</label>
</div>
</fieldset>
</div>
</div>
</div>
<div class="fsSection fs1Col" id="fsSection134542746">
<div class="fsSectionHeader">
<h2 class="fsSectionHeading">Support Groups and IOP</h2>
</div>
<div id="fsRow4101556-90" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell134542773" lang="en" fs-field-type="checkbox"
fs-field-validation-name="In addition to counseling services, JFS also offers free support groups and an Intensive Outpatient Program (IOP). If you're interested in signing up or receiving more information, please check the program(s) you are interested in. ">
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<p>For more information on our groups, please visit the <a href="https://www.jfshouston.org/jfs-central/bmhs-support-groups" rel="noopener noreferrer" target="_blank">JFS Houston website. </a></p>
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</form>Name: email-form — GET
<form id="email-form" name="email-form" data-name="Email Form" method="get" aria-label="newsletter signup"><label for="firstname-newsletter-2" labelfor="firstname-newsletter" class="field-label">First Name</label><input type="text"
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* Services Request Service Donate * About Us * Resources & News * Houston Jewish Family Foundation * Shop Celebration Company what are you searching for? * About Us * Leadership * Our Impact * Financials * Contact Continually measuring our impact to improve the quality of our services. Our Impact * Services Services Behavioral & Mental Health Services Licensed mental health professionals assist adults, adolescents, children and families to improve their overall well-being. Coaching & Case Management Providing individuals and families with access to information related to life’s challenges. Disability Services Enriching and empowering individuals with disabilities, their families and caregivers. Career and Professional Development Vocational rehabilitation services, job counseling, assessment, placement and support. Jewish Chaplaincy Providing spiritual comfort and guidance for patients and their families. Explore all services * Services * Events * Get Involved Get Involved Ways to Give Volunteer & Teen Opportunities Family Activities For the Good of Life Campaign Request Service Donate * About Us About Us Leadership Our Impact Financials Contact US * Resources & News * Houston Jewish Family Foundation Houston Jewish Family Foundation * Shop Celebration Company Request Service Donate Explore All Services We offer a family of services that support and transform the lives of individuals, families and communities. JFS Services Covid-19 See how JFS can help you deal with the impact of the pandemic. Learn More Behavioral & Mental Health Services Licensed mental health professionals assist adults, adolescents, children and families to improve their overall well-being. Counseling High-quality therapy for both adults and children. AdultsChildren & TeensGrief & LossIntensive Outpatient ProgramSupport Groups / Individual SessionsInsurance & FeesPay My Bill Community intervention Programs to raise awareness and knowledge. PreventionWellnessMental Health First AidSources of StrengthSubstance MisuseTouching the Heart Professional Development Continuing education for students and professionals in the mental health field. Continuing Clinical Eduction (CEU)Clinical Supervision & ConsultationPlay Therapy TrainingClinical Internships Community Request Providing resources to communities affected by loss or trauma. Continuing Clinical Eduction (CEU)Clinical Supervision & ConsultationPlay Therapy TrainingClinical Internships Suicide Prevention Coaching & Case Management Providing individuals and families with access to information related to life’s challenges. Senior Adult Helping seniors stay independent for as long as possible. Direct ServicesSenior OutreachSenior Chavurot Disaster Services Guiding those impacted through a long-term recovery. COVID-19Winter Storm 2021Disaster PreparednessFlood AssistanceHurricane PrepardnessDisaster Resources Financial Stability Providing classes and resources. Student Loans & ScholarshipsCaregiver Financial Empowerment Study Student Loan & Scholarship Enim ullamcorper viverra hendrerit sed ut. Family & Children Helping parents and families address the root of challenges they experience. Disability Case Management Providing access to information, referrals and planning. Holocaust Survivors Disability Services Enriching and empowering individuals with disabilities, their families and caregivers. Celebration Company An entrepreneurial employment program for adults with disabilities. About the Celebration CompanyAdmissionsCenter for Art & PhotographyCelebration Company News Shop Celebration Company Community Programs Focusing on inclusion and independence. EmploymentSocial SupportTransition Aged Programs Alexander Institue for Inclusion Lowering stigmas related to people with disabilities. About the InstituteCommunity Advocacy ReelAbilities disability Case Management Providing access to information, referrals and planning. disability Resource Guide Employment services Career counseling, disability training for employers, vocational rehabilitation services, assessment, placement and support. Career & Professional Development Enim ullamcorper viverra hendrerit sed ut. Career and Professional Development Coaching and resources for job-seekers and those planning to change careers. Employment Partners Create mutually beneficial relationships to provide employment opportunities. For Employers Diversify your workforce and promote inclusion MainStreet Opportunities A job counseling service to assist individuals with disabilities. Career Advancement A training program for young adults, ages 19-35. Job Search Guide MORE Fee SchedulePay My Bill Chaplaincy Providing spiritual comfort and guidance for patients and their families. Direct Services Including home visits, family meetings, information and referrals. Community connections Offering a variety of resources and information. Local SynagoguesJewish OrganizationsKosher Food and RestaurantsTemporary Housing Hospital Partners Serving the Texas Medical Center WAYS TO GIVE VOLUNTEER & TEEN OPPORTUNITIES FAMILY ACTIVITIES FOR THE GOOD OF LIFE CAMPAIGN Explore * Behavioral & Mental Health Services * Counseling * Counseling Request BEHAVIORAL AND MENTAL HEALTH SERVICES REQUEST We provide a safe and supportive environment with licensed mental health professionals to assist adults, adolescents, children, couples, and families to improve their overall well-being. REQUEST SERVICE All information provided in this form will be submitted directly to the Behavioral and Mental Health Service of Jewish Family Service Houston and will be kept strictly confidential. All requests submitted will be followed up by phone or email. JFS seeks to provide services to over 30 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. Contact Us Directly adultcounseling@jfshouston.org (713) 986-7832 Hours of Operation 8:30 AM – 8:00 PM Monday 8:30 AM – 5:30 PM Tuesday - Thursday 8:30 AM – 4:00 PM Friday Need Help Now? If you feel that you are in an emergency, please reach out to these emergency resources. Call 911 or the 24 hour helpline at (713) 970-7000 or text "START" to 741-741. Houston Crisis Hotline (866) 970-4770 National Suicide Prevention Lifeline 988 suicidepreventionlifeline.org The Trevor Project, LGBTQ Crisis Hotline (866) 488-7386 National Domestic Violence Hotline: (800) 799-SAFE (7233) www.thehotline.org For current JFS clients, please provide an update to your JFS staff. For clients who are seeking JFS services for the first time, please inform the JFS staff about the recent care received through any emergency resources. Please fill in a valid value for all required fields Please ensure all values are in a proper format. Are you sure you want to leave this form and resume later? Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form. Save and Resume Later Save and get link You must upload one of the following file types for the selected field: There was an error displaying the form. Please copy and paste the embed code again. Apply Discount You saved with code Submit Form Submitting Validating There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue. Please check the field: Fields Behavioral and Mental Health Services Request Form JFS Houston is currently offering both telehealth services via our HIPAA compliant online provider (Zoom) and in-person services. Client Name* First Name* Last Name* Client Age* Child Adult Phone* Email* Preferred Contact Method* Phone Email May we leave a message? Yes No Address* Address Line 1 Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code Date of Birth* https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 Race* African American/Black African Asian /Asian American Hispanic/LatinX or Spanish Origin (any race) Indigenous People or Native Americans (American Indian or Alaska Native) Middle Eastern or North African Multiracial (Two or more races) Native Hawaiian or Other Pacific Islander White Not listed Unknown Religion* Client's Sex* Male Female Other Client's Gender* Female Male Non-binary (non-conforming) Transgender Female Transgender Male Not listed/other Preferred Pronouns* He She They United States Veteran * Civilian Veteran Active Duty Widow/Widower of Veteran Not Disclosed Marital Status* Single Married Widowed Cohabitating Divorced Separated Parents' Marital Status* Biological parents married Biological parents divorced Biological parents never married Cohabitating Widowed Foster parent(s) Adoptive parent(s) Other: Other Value Primary Language* English Spanish Other: Other Value Primary Language of Parent* English Spanish Other: Other Value What are you seeking counseling for? * I am aware that if I am experiencing a life-threating emergency, I will call 988 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).* Yes I am aware that if my child is experiencing a life-threating emergency, I will call 988 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). * Yes Do you currently receive any other mental health services? * Yes No What kind?* Any diagnosis? * Have you received mental health services in the past?* Yes No Elaborate: * In the last 30 days, have you been hospitalized for mental health reasons or attended an IOP/PHP program?* Yes No Name of hospital/program: Date of discharge: https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2018 2019 2020 2021 2022 2023 Any current legal issues we should know about? (divorce, child custody, DWI, assault, etc.) * Yes No Select all issues that client/clients' caregivers have experienced:* Divorce Child custody DWI Assault Other: Other Value Any safety concerns (restraining orders)?* Yes No What kind? What court? * Any current medical issues that are important for us to know about?* Yes No What kind? * Did you flood in 2017?* Yes No Are you referred by your EAP? * Yes No Are you new to JFS Houston? * Yes No Other JFS services used:* Senior Services Financial Aid Employment Family & Counseling Celebration Company Disaster Services Volunteering Other: Other Value Are you new to counseling services at JFS?* Yes No Best days and times for appointments (no weekend availability):* I prefer:* In person session Telehealth sessions Open to both Who referred you to us: Please upload image of your ID (for children, upload ID of primary insurance holder) No File Chosen File uploads may not work on some mobile devices. Payment Information Please select one of the following: * I HAVE health insurance I do NOT have health insurance I choose not to use my insurance and I agree to pay full price for my services I am willing to see a clinical Intern who is under supervision for a reduced fee and a shorter wait time.* Yes No Good Faith Estimate If you don't have health insurance or are not using your insurance to cover your cost of your services, you have the right to receive a “Good Faith Estimate” explaining how much your services will cost before services are provided. * You have the right to receive a Good Faith Estimate for the total expected cost of any services upon request or when scheduling such services within a designated timeframe. * You have the right to dispute the bill if it is at least $400 more than your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1- 800-985-3059. Financial Information We collect financial information to determine the fee which is based on a sliding scale. It is determined by your household income and number of people living in your household. Monthly Income* Number of people living in your household (include all adults and children)* Name First Name Last Name Relationship Birthdate https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Name of Person 2 First Name Last Name Relationship with Person 2 Birthdate of Person 2 https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Name of Person 3 First Name Last Name Relationship with Person 3 Birthdate of Person 3 https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Name of Person 4 First Name Last Name Relationship with Person 4 Birthdate of Person 4 https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Please list names, relationship to you and birthdate of additional people living with you. If you have children in your household, are they enrolled in daycare or afterschool care? * Yes No N/A CAREGIVER INFORMATION Caregiver Name* First Name* Last Name* Relationship to Client: * Legal Guardian Power of Attorney Custodial Parent Relative Other: Other Value Do you have signed legal documents? * Yes No Please bring copies Caregiver Phone* Caregiver Email* Caregiver Address* Address Line 1 Address Line 2 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Armed Forces (the) Americas Armed Forces Europe Armed Forces Pacific Army Post Office (U.S. Army and U.S. Air Force) Fleet Post Office (U.S. Navy and U.S. Marine Corps) State ZIP Code HEALTH INSURANCE INFORMATION Insurance Company Name * Policy Holder Name* First Name* Last Name* Date of Birth of Policy Holder* https://jewishfamilyservicesajivu.formstack.com/forms/images/2/calendar.png Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 Phone Number on the Back of the Card* Member ID #* Group #* Please upload image of front of insurance card. No File Chosen File uploads may not work on some mobile devices. Please upload image of back of insurance card or secondary insurance if you have one. No File Chosen File uploads may not work on some mobile devices. FREE SUPPORT SESSIONS JFS offers two free support sessions that can be provided while you are on the waitlist to see a therapist. Support sessions are not therapy and are meant to provide resources and support during the intake process wait time. Are you interested in registering for 2 free support sessions? Yes No I understand that the purpose of the support session is limited to facilitating strength-based support and is not considered mental health counseling or therapy. Yes No What day of the week are you available for your support session? Monday Tuesday Wednesday Thursday Friday What time of day would you prefer your support session be scheduled? Morning support session Afternoon support session Would you prefer your session to be: Virtual In-person Either SUPPORT GROUPS AND IOP In addition to counseling services, JFS also offers free support groups and an Intensive Outpatient Program (IOP). If you're interested in signing up or receiving more information, please check the program(s) you are interested in. Men's Group (55+): Mondays, 1:00-2:00 PM (Virtual and in-person at JFS). FREE Women's Group (Adults): Wednesdays, 1:00-2:00 PM (Virtual). FREE Mindfulness Group: Thursdays, 8:00-9:00 AM (Virtual). FREE Grief Support Group: Thursdays, 1:00-2:00 PM (Virtual). FREE LGBTQIA Support Group (Adults): Wednesdays, 5:30-6:00 PM (Virtual). FREE Emerging Adults Group: Mondays, 5L30-6:30 PM (Virtual) FREE Please indicate if you are interested in receiving more information about UPCOMING groups: IOP: 8 week program, Tuesday through Thursday (In-person). FEE BASED Elementary children's support group. FREE Middle School children's support group. FREE High-school aged support group. FREE DBT Skills Group for Adolescents (12 to 17). FEE BASED LGBTQIA Support Group (Teens). FREE Parenting skills groups and classes. FEE BASED The Tulip Group. FREE For more information on our groups, please visit the JFS Houston website. Previous← Next→ Enter your save and resume password Cancel Confirm Online Form - BMHS Counseling Request Powered by Formstack Contact Us Directly adultcounseling@jfshouston.org (713) 986-7832 Hours of Operation 8:30 AM – 8:00 PM Monday 8:30 AM – 5:30 PM Tuesday - Thursday 8:30 AM – 4:00 PM Friday Need Help Now? If you feel that you are in an emergency, please reach out to these emergency resources. Call 911 or the 24 hour helpline at (713) 970-7000 or text "START" to 741-741. Houston Crisis Hotline (866) 970-4770 National Suicide Prevention Lifeline 988 suicidepreventionlifeline.org The Trevor Project, LGBTQ Crisis Hotline (866) 488-7386 National Domestic Violence Hotline: (800) 799-SAFE (7233) www.thehotline.org For current JFS clients, please provide an update to your JFS staff. For clients who are seeking JFS services for the first time, please inform the JFS staff about the recent care received through any emergency resources. No items found. RESOURCES & NEWS A central location for you to be empowered with knowledge. Explore JFS Central Carl’s Daily , Helpless But Not Powerless - April 15, 2021 Carl’s Daily , The Sacred Nature of Self-Care -May 27, 2021 Carl’s Daily , Not Finished But Resting - April 30, 2021 Carl’s Daily , Finding Our Second Wind - January 6, 2021 Support Alexander JFS We rely on the gifts of many to deliver our services. Please consider being a partner in our vital work. 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