Nominations

JCIL Intake Form

* Indicates required field

Name *

First

Last

Date *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Cell Phone Number *

Date of Birth *

Gender *

Race *

Do you have a legal guardian or power of attorney (POA)? *

Yes No

Guardian or POA Name *

First

Last

Guardian or POA Address *

Line 1

Line 2

City

State

Zip Code

Country

Guardian or POA Best Phone Number *

Guardian or POA Email *

Ethnic Origin *

Hispanic/Latino Other

Are you a Registered Voter? *

Yes No

If no would you like to register? *

Yes No

Are you a Veteran? *

Yes No

SSI/SSDI/VA? *

Yes No

Are you in the process of transitioning from a facility? *

Yes No

Number in Household *

Number of Children *

Head of Household? *

Yes No

Marital Status *

Living Situation? (Rent, Own, Live with Family/Friend, Homeless) *

Is your home accessible? *

Yes No

Do you have reliable transportation? *

Yes No

Do you use any other kind of special equipment throughout the day? (wheelchair, rollator, walker, ect) *

Yes No

Do you use any specialized equipment in the bathroom? (Shower grab bars, toilet bars, seat riser, shower chair) * *

Yes No

Do you need assistance with dressing, toileting, eating, or grooming? *

Yes No

Do you have to be reminded to dress, eat, bathe, ect? *

Yes No

Do you need someone to fix/cook your meals, do the shopping, or do household chores? *

Yes No

Do you need help with managing your money? *

Yes No

Do you have difficulty in understanding others or understanding verbal instructions? *

Yes No

Do you have enough food in your home? *

Yes No

Do you need assistance getting SNAP benefits or commodities? *

Yes No

Do you have gainful employment? *

Yes No

Do you want gainful employment? *

Yes No

Do you currently have health insurance? *

Yes No

Do you have a significant disability? *

Yes No

Primary Disability *

Additional Comments *

My disability(ies) substantially limit(s) me from functioning independently in the following area (s) *

Other *

The services I am requesting will help me: (Please check all that apply) *

Improve my ability to function in my family or community. Maintain my ability to function in my family or community. Obtain, maintain or advance in employment.

Any request for services or equipment is subject to approval and availability. Upon approval you will be notified.

JCIL provides equal services to all persons without regard to race, color, religion, disability, sex, age or national origin. Any consumer with a complaint concerning services provided by the Jackson Center for Independent Living (JCIL) or believes that they were discriminated against based on a category – i.e., race, sex, age, disability – recognized by federal, state and/or local civil rights laws has the right to file a grievance according to the procedures outlined in this policy. *

I Understand

Full Consumer Grievance Procedure Information can be found here

I give permission for JCIL Center grantors to review my files as necessary. *

Yes

I certify all information is true and correct to the best of my knowledge. *

Yes

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this form. *

I Accept

Client Assistance Program (CAP): A Client Assistance Program is available to help you if you need information and advice about services under the Rehabilitation Act. If you ask for help, their staff may provide assistance to ensure that your rights under the Rehabilitation Act are protected. You may contact CAP through: Disability Rights TN 2693 Union Avenue Extended Suite 201 Memphis, TN 38112 1-2800 342-1660 Email: GetHelp@disabilityrightstn.org *

I Understand

Submit