Youth Anxiety Programs Form -

125th Anniversary
Call Now
Donate
Make A Payment
Patient Portal Login

Who We Are
What We Do
How To Help
Resources
Contact

125th Anniversary
Call Now
Donate
Make A Payment
Patient Portal Login

Who We Are
What We Do
How To Help
Resources
Contact

Youth Anxiety

Client Information

Which youth anxiety program are you interested in participating in?(Required)

JFS Wilmington Office: Starting September 9

JFS Newark Office: Starting September 11

Individual SPACE treatment for parents to learn skills and tools to help their child overcome anxiety

Child's Name(Required)

First Last

Child's Date of Birth(Required)

MM slash DD slash YYYY

Parent/Guardian Name(Required)

First Last

Phone Number(Required)

What is the best phone number to reach you?

Can we leave a message at the phone number you provided?(Required)

YES

NO

Email(Required)

What is your preferred email address?

Address(Required)

Street Address Address Line 2 City State ZIP Code

Child's Race

Specify here:

Would you like to share more details?

Child's Ethnicity

Preferred Language

Do you have insurance?(Required)

YES

NO

Primary Insurance Carrier(Required)

Policy #(Required)

Policy Holder's Name(Required)

First Last

Policy Holder's Date of Birth(Required)

MM slash DD slash YYYY

Do you have secondary insurance coverage?(Required)

YES

NO

How did you hear about us?

(select any/all that apply)

Friend / Family Member

A Current JFS Client

JFS Website

Social Media

Website Advertisement

Radio Advertisement

School Referral

OTHER

If you selected OTHER, please specify here:

Our Partnerships

- - Contact Us
  - Donate
  - Volunteer
  - Sitemap
  - FAQ
- Wilmington Office
  99 Passmore Road
  Wilmington, DE 19803
  302-478-9411
  Sussex Office
  20684 John J. Williams Hwy Ste 4
  Lewes, DE 19958
  302-827-6040
- NEWARK OFFICE
  261 Chapman Road Suite 103
  Newark, DE 19702
Join Our Newsletter

Email(Required)
Copyright © 2025 Jewish Family Services
- Privacy Policy