Community Health Crisis Needs Intake Form

The Jewish Federation, led by the Health Crisis Management Team, is orchestrating the delivery of essential needs to those most impacted by social distancing and quarantine due to COVID-19. If you or a loved one are homebound and or in need of assistance, and not currently participating in current programs or services offered by JFS and the JCC, please complete the form below. These requests are being reviewed 3 times a day and a member of the Jewish Federation’s professional team will be in touch with any questions. Please note that we cannot guarantee the provision of all goods. If you have an urgent need please call the Help Line below. If your urgent need is medical, please call 911.

**While efforts will be made to ensure that personal information is only shared as needed for the provision of goods, please note that information submitted through this form will be shared between agencies, staff, and volunteers to best-deploy limited resources that are available. Your submission of this form is an acknowledgment that you understand these limitations upon your privacy, that you voluntarily choose to participate and share your information, and that you agree to waive your legal privacy rights, including those under HIPAA.

Help Line: 214.615.5241

Monday-Thursday (9 am - 5 pm)

Friday (9am - 3 pm)

Question Title

* 1. Please complete the following for the individual in need:

Name

Address

City/Town

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2. If you are completing the form on behalf of an individual, please provide your contact information.

Name

Address

City/Town

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 3. What is the best way for us to contact you?

Phone

Question Title

* 4. Are you currently receiving services from JFS, the JCC, or other local Jewish organization? If so, who are you working with?

Yes

Please provide details on services currently received.

Question Title

* 5. How did you learn about this opportunity?

Jewish Federation of Greater Dallas

Aaron Family JCC

Jewish Family Service

The Legacy Senior Communities

CHAI

My synagogue (please specify which one in the space below)

My Child's school (please specify which one in the space below)

Facebook

Texas Jewish Post (TJP)

From a friend or family member

Other

Other (please specify)

Question Title

* 6. Please select the item(s) and/or services most needed:

Prepared Meals

Gift Card

Counseling and Mental Health Services

I require Kosher food

Please provide details (as appropriate) for the items/services requested.

Question Title

* 7. Please feel free to describe your situation and any needs that require more information. Please note that this information is not protected by HIPAA regulations and will be shared with the appropriate community organizations to best respond to the request.

Question Title

* 8. **I agree that the submission of this form is an acknowledgment that I understand the limitations of my privacy and that I voluntarily choose to participate and share my information and agree to waive my legal privacy rights, including those under HIPAA.

*Please note that selecting "No" inhibits our ability to deliver necessary services and goods. Please call our HELP LINE at 214.615.5241 or JFS at 972.437.9950. Help Line is available Monday - Thursday (9 am - 5 pm and Friday (9 am - 3 pm)

Yes