General Request for Benefits Counseling -

Referral Form for Benefits Counseling

This form is specifically for the social worker or friends/family memebers to request information and assist their own client or loved one.
*Depending on your questions and situation, our front desk staff may be able to assist you with general information.

It may take up to 2-3 weeks for a phone consultation. 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 related to the person with the disability are what the Benefits Counselor needs to know to assist you.m.

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

Referral for Benefits Counseling Services

Information and Referral (I&R form)
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Please tell us you you are:*

I am a professional from an agency/business requesting information and working with someone with a disabailityI am a friend or family memeber of a person with a disability, requesting information for the person with a disability
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
Your Phone Number with area code (and extention if applicable) *
If Work #: please list your extention
The number above is a:*

Mobile/CellHouse/Land lineOffice/Work
What is your Mailing Address?*

Name of the agency you work for OR Street Address Line 1

Street Address Line 2 (Apt# or Suite #)

CityState / Province

Postal / Zip Code
Your E-mail address:*
example@example.com
Would you like to be added to our email list? We periodically share information on human/disability rights, accessibility, housing, special education, and community engagement information. You can unsubscribe at any time*

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

An application denied for SSI/SSDI within the past 30 days.An application denied for SSI/SSDI *OVER 30 days ago.Overpayment notice, and I don't know how to help them appeal it.*Other Social Security forms and notices (Please provide further detail below)They currently have SSI/SSD and are wanting to go back to work. How does earned income affect their benefits including Medicaid and Medicare?How to help them apply for Disability Benefits
If there is a deadline on the notice. What is the deadline date?*
If there is no specific date, but it says 15 days from the date of this notice, then calculate what the deadline is from the date of that notice.
The name of the individual with the disability:*

First NameLast Name
Their Phone Number*
Please enter a valid phone number.
Their mailing address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Their email address:
example@example.com
What is their disability? *
What is their marrital status?*

SingleMarried (even if you are separated)DivorcedWidowed
Are they the head of their household*

YESNO
How many people live their household, including them? *
if it's just them, enter "1".
What are their current sources of Income? Only check what they currently recieve, NOT what they are applying for:*

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
What is their current Housing Status?*

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 (Homeowner)They own their own House/Condo
Please provide any additional information about the individual with the disability:*

0/1500
After you click on SUBMIT, our front desk staff will respond to your request via email within a few business days.

You may be directed to attend an upcoming workshop before scheduling an appointment.
Should be Empty:

Referral Form for Benefits Counseling

Referral for Benefits Counseling Services