SOARSSI/SSDI Outreach, Access, and RecoveryWORKS

SOAR Referral Application

Please complete in full and fax to: Yvette Hynson 410-770-4809
Candidate Name
Date of referral

MonthDayYear
Date
Referring agency
Person making referral
Staff contact number
Email address
example@example.com
Candidate Identifying Information:
Date of birth

MonthDayYear
Date
Gender
(must be within 30 days of 18 years of age, or within 180 days if exiting foster care)
Race
Marital Status
SSN
Current living arrangement (address shelter area of town)
Education last grade completed
Employment status
Veteran
Telephone Number
Emergency Contact Person/Telephone Number
Part A: Homelessness/At-Risk Assessment

Where is the candidate currently living? Check the apporpriate selection
HOMELESS

OutdoorsShelterTransitional Housing
AT-RISK FOR HOMELESSNESS

Doubled up/couch-surfingReceived eviction notice or has substantial arrears in rent/utilitiesPermanent supportive housing that is grant funded(Housing First placements)Exiting foster careInstitution – hospital, nursing home, etc.Jail
If homeless, how long has the candidate been homeless:
Years
Months
If the candidate is in an institution or jail, is he/she expected to be released within 30 days?

YesNo
Was he/she experiencing homelessness before entering the facility?

YesNo
Has the candidate had difficulty maintaining housing?

YesNo
If yes please describe
Part B: Current Application for SSA Benefits or Pending Appeal
Has the candidate recently applied for Social Security benefits?

YesNo
If yes, date

MonthDayYear
Date
What was the decision on your application?

PendingDenied
(If denied) Did the candidate appeal? Is he/she waiting on a decision? Is he/she working with a lawyer?
Part C: Diagnostic Information
Please list all mental and physical health diagnoses
Where has the candidate been treated for these conditions
Current medications and prescribing physician/agency
Does the candidate have a history of substance use? (Prior or current substance use is not a disqualifying factor for SOAR)

YesNo
Last substance(s) used
Last known date of use

MonthDayYear
Date
Part D: Narrative questions for SOAR eligibility

Ask these questions to the candidate and record answers
1. Can you tell me about why you are looking to apply for Social Security benefits
2. When was the last time you were able to work? Why did you leave that position? Can you tell me about any times you have tried to work in the past couple of years? (If candidate is currently working): Tell me about your job: How many hours per week do you work? How much do you earn each month? Is there anything you struggle with while on the job or find difficult about your work?
3. Tell me about any ways that your conditions make things difficult for you on a daily basis: Do you notice any difficulties with day-to-day activities? Do you have trouble getting along with others or feeling like you want to avoid people? Have you noticed any changes in your memory?
Summary and Next Steps

To assess SOAR eligibility we are looking for basic information on:
- The presence of medical and/or psychiatric conditions or symptoms which would fit an SSA listing
- Current treatment, or a history of treatment for conditions
- Inability to work and earn SGA ($1,180/month in 2018) due to medical and/or psychiatric conditions (not because he/she can not find work or was laid off)
- Impairments in functioning due to medical and/or psychiatric conditions
SOAR specialists will contact the candidate to follow up on information provided on this form. A full intake assessment may be required to gather additional supporting evidence to determine if we can assist the candidate with a SOAR application.
SOAR Referral Follow-up
Candidate Name
Date referral received

MonthDayYear
Date candidate contacted: If unable to contact list dates of contact attempts
Notes from call/meeting with candidate
Next Steps:

Intake assessment is NOT appropriateCandidate is Eligible for intake assessment
If intake assessment is NOT appropriate. List reason and follow-up resources or referrals provided
If candidate is Eligible for intake assessment, they will have:

Active placementWaitlist placement. Initial appointment to be scheduled at a later time.
(If active placement) Initial appointment for screening scheduled for

MonthDayYear
Date
SOAR Staff Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

SOAR Referral Application

Candidate Identifying Information:

Part A: Homelessness/At-Risk Assessment

Part B: Current Application for SSA Benefits or Pending Appeal

Part C: Diagnostic Information

Part D: Narrative questions for SOAR eligibility

SOAR Referral Follow-up