Jewish Family and Career Services of Atlanta
4549 Chamblee Dunwoody Road
 Client Information
  First Name:  * Last Name:  *  
  Date of Birth:  * Gender:  *  
  Address: City:  
  State: Zip Code :  
  Phone No:  
This is an eligibility screening form. Submission of this form does not guarantee approval of financial assistance. After your screening form is reviewed a JFCS staff member will call to discuss how we can help. We ask that you answer all questions as this information assists us in measuring need across Atlanta communities.

* Best Contact Phone
Referred By:
* County:
* Gender:
* DOB:
* Marital Status:
* Race:
* Religion:
* Number in Household
* Are you now or have you previously been a client of JF&CS?
If yes:
Current   Past  
Current Counselor:
* I need assistance with:
Housing Expenses 
Health Related Expenses 
Transportation Expenses 
Legal Expenses 
Child/Dependent Adult Care Expenses 
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Cancel" button to exit without saving recent updates on this form.