JFCS Intake Portal

All information is strictly confidential.

Please read thoroughly and fill out the form completely as it pertains to yourself, or the person you are helping.

Each section of the form is validated before you can progress to the next.

Basic Information

Required

Full Name

This field is required.

Maiden/Other Last Name

This field is required.

Email

Please provide a valid email address.

Address or PO Box

This field is required.

City

This field is required.

State

This field is required.

Zip

This field is required.

Country

This field is required.

Preferred Phone

Please enter a valid phone number in the format of 123-456-7890

Ok to leave message?

Ok to leave TEXT?

Secondary Phone

Please enter a valid phone number in the format of 123-456-7890

Ok to leave message?

Ok to leave TEXT?

Date of Birth

Please enter a valid date in the format of mm/dd/yyyy. For example, 05/21/1972

Gender

Please select one.

Demographics

Referrals

Education

Highest grade completed

This field is required.

Employment

Employment/School/Training Status

This field is required.

Occupation

This field is required.

Current Annual Household Income (Gross)

This field is required.

Household

Household Size: # of Adults

This field is required.

Household Size: # of Children under 18

This field is required.

List adults/children living in household:

Instructions: Click on the button above to to add a household member. Click on the next to a name to remove a member.

All fields for each member are required

Gender

DOB

Relationship

Gender

DOB

Relationship

Gender

DOB

Relationship

Gender

DOB

Relationship

Parent/Guardian/Caregiver

Caregiver Name

This field is required.

Caregiver Address

This field is required.

Caregiver Phone Number(s)

This field is required.

This person is my

This field is required.

Emergency Contact

Emergency Contact Name

This field is required.

Emergency Contact Phone Number(s)

This field is required.

Medical Insurance

I have

OHP/Care Oregon (Medicaid)

WA State Plan (Medicaid)

Medicare

Private Insurance

No Insurance

This field is required.

Notice of Privacy Practices

I understand that Jewish Family & Child Service will use and disclose health information about me. I understand that my health information may include information both created and received by the practice/facility, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

I understand and agree that Jewish Family & Child Service may use and disclose my health information in order to:

Make decisions about and plan for my care and treatment:
Refer to, consult with, coordinate among, and manage along with other health care providers and agency staff for my care and treatment;
Determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and
Perform various office, administrative and business functions that support my practitioner/provider's efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.

I also understand that I have the right to receive and review a written description of how Jewish Family & Child Service will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of Jewish Family & Child Service, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of Jewish Family & Child Service’s Notice of Privacy Practices in effect will be posted in waiting/reception area.

I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that Jewish Family & Child Service is not required by law to agree to such requests.

I understand that it is Jewish Family & Child Service Policy to obtain my signature on a Release of Information whenever possible.

By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.

You must agree to this.

Patient or Patient's Representative Signature

You must type your name in.

Relationship to Patient

Please enter your relationship to patient. If you are the patient, type self.

Authorization to Use/Disclose Health and Case Management Information

I authorize Jewish Family & Child Service to use and disclose Health and /or Case Management information, and a copy of the specific health and clinical information described below regarding:

Patient/Client Name

Date of Birth

Consisting of: Assessment and case notes referring to billing

Medical Treatment Initials Your initials are required.	Medical Treatment; Alcohol / Drug Treatment; Psychiatric Treatment; HIV Tests, Diagnosis, Treatment; Mental Health Treatment; Financial Information; Disability Information
Unless otherwise specified, Medical Treatment, Psychiatric Treatment, Mental Health Treatment, and Alcohol / Drug Treatment may include all aspects of diagnosis, treatment and prognosis.

To: INSURANCE PROVIDER

For the Purpose of: BILLING

Your health care and payment for that health care cannot be conditioned upon receipt of this signed Authorization unless your health care or treatment is for the purpose of:

(1) Creating health information about you to be disclosed to a third party; or

(2) For the purpose of research.

You have the right to revoke this Authorization at any time, provided that you do so in writing. If you revoke your Authorization, we will no longer use or disclose information about you for the reasons covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.

To revoke this Authorization, please send a written statement to:

JFCS Program Manager
1221 SW Yamhill St, Suite 301
Portland, OR 97205

Your statement must identify the date you signed this Authorization, the recipient of the information identified in this Authorization, and state that you are revoking this Authorization. This Authorization will expire 180 days from the date of signing, or the end of the period reasonably needed to complete the disclosure for the above-described purpose, whichever comes firs.

I have reviewed and I understand this Authorization. By signing this Authorization, you are directing us to disclose your health information to another person or organization that may not have or obey the same obligations to protect privacy that we do under state and federal law. Therefore, the disclosure of the information specified above carries with it the potential for an unauthorized re-disclosure and loss of protection under state and federal law.

You must agree to this.

Patient or Patient's Representative Signature

You must type your name in.

Relationship to Patient

Please enter your relationship to patient. If you are the patient, type self.

Telemental Health Informed Consent Form for Jewish Family & Child Service

I, , consent to mental health treatment and/or other JFCS provided services through the use of technology (this includes audio, video, email, and other electronic communication) between myself and my provider and/or case manager, who is an employee of Jewish Family & Child Service. This communication will be conducted through technologies that are HIPAA compliant.

(1) I have the right to withdraw my consent for telemental health services at any time. This does not affect my eligibility for services through Jewish Family & Child Service in any way.

(2) The laws that protect my personal information are also applicable to telemental health services. I understand that I have the right to my mental health information and records. I also understand that in the event of an emergency, my clinician is required by law to do everything in his or her power to ensure my safety.

My physical location during sessions in case of an emergency,

You must enter your location.

Emergency Contact/Phone Number

(3) I understand that the use of technology for mental health services carries risks. While my JFCS clinician and/or case manager will attempt to ensure confidentiality and quality service, there are risks including breach of confidentiality, theft of information, or service disruptions related to technical failures. I also understand that telemental health service may not be as wide-ranging as those of services provided face-to-face.

(4) My clinician and/or case manager and I will continually review the need and appropriateness of telemental health services and/or other services as a means to deliver services to me.

By signing this document, I acknowledge that I have read and understand the information provided above.

You must agree to this.

Patient or Patient's Representative Signature

You must type your name in.

Relationship to Patient

Please enter your relationship to patient. If you are the patient, type self.