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125th Anniversary
Call Now
Donate
Make A Payment
Patient Portal Login
Who We Are
About Us
Our History
Meet Our Team
Join Our Team
Board Of Directors
Equity Diversity & Inclusion
Financial Reports
Our Partners
What We Do
Mental Health
Cancer Care
Older Adult Services
Dementia Care
Support Services
Refugee Services
How To Help
Donate
Ways to Donate
Season of Giving
Volunteer
Join Our Team
Resources
Blog
Coping with Difficult Times
Podcast
Press & News
Newsletter Archive
Request for JFS Services
Make A Payment
Contact Us
FAQ
Contact
Contact Us
FAQ
Newsletter Sign-Up
Youth Anxiety Programs
Client Information
Which youth anxiety program are you interested in participating in?
(Required)
Dover Public Library: Mondays from 3-4 PM | June 24 - August 26 | Youth and Teens
Client Name
(Required)
First
Last
Client 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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Client Race
[Select from drop-down menu]
American Indian / Alaskan Native
Asian
Black / African American
Native Hawaiian / Other Pacific Islander
White / Caucasian
More than one race
Prefer not to disclose
Specify here:
Would you like to share more details?
Client Ethnicity
[Select from drop-down menu]
Hispanic / LatinX
Non-Hispanic / Non-LatinX
Prefer not to disclose
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:
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