General Request for Benefits Counseling -

General Request for Benefits Counseling

This is not an Intake to become a consumer of TRI. Once you speak to the Benefits Counselor, they will inform you to complete an Intake Packet.
*This is an Information & Referral form. Depending on your questions and situation, our front desk staff may be able to assist you with general information. When in need of further assistance or guidance you may then be directed to complete an Intake Packet and assigned to an Advocate.

It may take up to 2-3 weeks for the Benefits Counselor to be available to meet with you one-on-one or return your call. Therefore, if you are inquiring about Applying for Social Security or are interested in the Work Incentives, you must attend a workshop first. You'll find how to register for the workshop on our website: https://taconicresources.org/mobile-disability-benefits-counseling/

As a non-profit funded by NYS Education Department's Adult Career and Continuing Education Services-Vocational Rehabilitation (ACCES-VR), we're obligated to collect the following contact information for funding purposes. The additional questions are what the Benefits Counselor needs to know to assist you.

Each question with a * must be answered.

If you are having difficulty completing this form, please call the front desk during our regular business hours (Monday through Friday, 9am-5pm EST) to assist you: 1-845-452-3913

General Request for Benefits Counseling Services

Or information and Referral
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
This request form is for the individual with the disability. If you are completing this form for someone else, please stop and go back to the website to complete the Referral Form.*

I am a person with a disability requesting services for myself
Your Legal Full Name*

First NameMiddle NameLast Name
Alias, Nick Name, Chosen Name you prefer to be called:
My Pronouns are:*
examples: he/him; she/her; they/them
I identify as a:*

OtherMaleFemale
List the best phone number to reach YOU with the area code. *
If Work #: please list your extention
The number above is a:*

Mobile/CellHouse/Land lineSomeone else's phone number because I don't have a phone of my own
If the phone number is not yours what is the FULL name of the person
First and Last Name
What role do they play in your life?
Are they your Care Manager, Mother, Father, Sibling, Friend etc...
What is your Physical address?*

Street Address (If you are a PROFESSIONAL, please include name of the agency you work for)

Street Address Line 2 (Apt# or Suite #)

CityState / Province

Postal / Zip Code
Is your physical address the same as your mailing address?*

YESNO (if no, provide your mailing address at the end of this form)
Your E-mail address:*
example@example.com
Would you like to be added to our email list serve? You will be informed of helpful information periodically, and you can opt out at any time*

YESNO- only email me for this inquiry
What are you requesting assistance with?*

I applied for SSI/SSDI, received a denial within the past 30 days.I applied for SSI/SSDI, received a denial OVER 30 days ago.I have an overpayment and I don't know how to complete the paperwork.I received other Social Security forms and notices (Please provide further detail below)I currently have SSI/SSDI and wanting to go back to work. How does earned income affect my benefits including Medicaid and Medicare?Applying for Disability Benefits
If you recieved a notice from SSA with a deadline. What is the deadline date?
Select the category(s) that your disability relates to:*

Cognitive (examples: epilepsy, learning disability, Autism, TBI)Mental Health (examples: emotional/behavioral disabilities, ADHD)Physical (example: back injury, cerebral palsy, other environmental related)Sensory (blindness, low vision, deafness, hard of hearing, other)
Optional to provide your specific disability/ diagnosis
What is your marital status?*

SingleMarried (even if you are separated)DivorcedWidowed
Are you the Head of your Household*

YESNO
How many people live in your household, including yourself? *
What are your current sources of Income? Only check what you currently recieve:*

None -$0Unemployment InsuranceNYS Disability Benefits (employer based short-term payments)Workers CompensationSSI- Supplemental Security IncomeSSP- State Supplemental ProgramSSDI- Social Security Disability Insurance (based on your work history)DAC- Disabled Adult Child disability benefitsDependent or Survivor's benefitsPension- retirement from your job (401K, IRA, etc)Social Security *Retirement benefitsVeteran's Benefits/Pension/AidChild Support PaymentsSpousal Support (Alimony, Maintenence)Rental/Boarders/Lodgers IncomeNo Fault Insurance BenefitsPublic Assistance- Cash Assistance from DCFS (DSS)Wages/Earnings from work
Your current Housing Status can affect your benefits. What type if housing are you currently living in?*

Institution (Nursing Home/Rehab)Subsidized Rental Property (based on income/ project based, or residential treatment program)Dependent on Family/Friend (lives with)No Shelter- sleep on street/ in carTemporary Shelter (assigned to a private room homeless shelter)The PODS - day/night shelterAssisted Living FacilityGoing through Foreclosure (I'm a Homeowner)I own my own House/Condo
Please provide any additional information:*

Example- if you have a different mailing address, and/or explain what the other notices you received are about.0/1500
After you click on SUBMIT, our front desk staff will respond to your request via email within a few business days.
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General Request for Benefits Counseling

General Request for Benefits Counseling Services