Home
Services
Information Referal
Peer Support
Advocacy
Skills Training
Deaf & Hard of Hearing Services
Home Modifications
Transition from Nursing Home
Equipment Program
Accessible Dining in Jackson Project
How Can I Help?
Contact Us
JCIL
Intake Form
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Indicates required field
Name
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First
Last
Date
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Email
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Address
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Address Line 2 - If Needed
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City
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State
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Zip Code
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County
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Phone Number
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Cell Phone Number
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Date of Birth
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Gender
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Race
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Do you have a legal guardian or power of attorney (POA)?
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Yes
No
Guardian or POA Name
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First
Last
[object Object]
Guardian/POA Address Line 1
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Guardian/POA Address Line 2
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Guardian/POA City
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Guardian/POA State
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Guardian/POA Zip Code
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Guardian/POA County
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Guardian or POA Best Phone Number
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Guardian or POA Email
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Ethnic Origin
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Hispanic/Latino
Other
Are you a Registered Voter?
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Yes
No
If no would you like to register?
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Yes
No
Are you a Veteran?
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Yes
No
SSI/SSDI/VA?
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Yes
No
Are you in the process of transitioning from a facility?
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Yes
No
Do you need any of the following accommodations?
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Braille Print
Digital Format
Large Print
Interpreter Services
None
Number in Household
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Number of Children
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Head of Household?
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Yes
No
Marital Status
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Living Situation? (Rent, Own, Live with Family/Friend, Homeless)
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Is your home accessible?
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Yes
No
Do you have reliable transportation?
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Yes
No
Do you use any other kind of special equipment throughout the day? (wheelchair, rollator, walker, ect)
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Yes
No
Do you use any specialized equipment in the bathroom? (Shower grab bars, toilet bars, seat riser, shower chair) *
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Yes
No
Do you need assistance with dressing, toileting, eating, or grooming?
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Yes
No
Do you have to be reminded to dress, eat, bathe, ect?
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Yes
No
Do you need someone to fix/cook your meals, do the shopping, or do household chores?
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Yes
No
Do you need help with managing your money?
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Yes
No
Do you have difficulty in understanding others or understanding verbal instructions?
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Yes
No
Do you have enough food in your home?
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Yes
No
Do you need assistance getting SNAP benefits or commodities?
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Yes
No
Do you have gainful employment?
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Yes
No
Do you want gainful employment?
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Yes
No
Do you currently have health insurance?
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Yes
No
Have you had the Covid Vaccination?
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Yes
No
Do you need help scheduling the vaccine
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Yes
No
Do you need a ride to take the vaccine
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Yes
No
Comment
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Other Agencies Currently Involved
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Home Health
LIHEAP
SNAP
Mental Health Services
State Program for Blind/Visually Impaired
State Program for Deaf/Hard of Hearing
None
Other
Do you have a significant disability?
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Yes
No
Choose Any
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Self-Identifies
Mental/Emotional
Physical
Hearing
Vision
Multiple Disabilities
Cognitive
Other
None
Primary Disability
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Additional Comments
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My disability(ies) substantially limit(s) me from functioning independently in the following area (s)
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Self-Care
Mobility
Education
Employment
Housing
Other (Specify Below)
Other
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The services I am requesting will help me: (Please check all that apply)
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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.
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I Understand
Full Consumer Grievance Procedure Information
can be found here
I give permission for JCIL Center grantors to review my files as necessary.
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Yes
I certify all information is true and correct to the best of my knowledge.
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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.
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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:
[email protected]
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I Understand
Submit
Home
Services
Information Referal
Peer Support
Advocacy
Skills Training
Deaf & Hard of Hearing Services
Home Modifications
Transition from Nursing Home
Equipment Program
Accessible Dining in Jackson Project
How Can I Help?
Contact Us