• SOAR Referral Application

  • Are you completing this form for yourself or are you completing this form for someone else?*

  • Referral Details

  • Format: (000) 000-0000.

  • Patient Information

    Please enter the requested information below
  • Preferred Language:
  • Do you have a Social Security Number?*
  • Have you served in the US Military (Army, Navy, Air Force, Marines, Coast Guard)
  • Are you a VET; do you qualify or use VA medical services?
  • Do you currently have medical insurance / coverage*
  • Do you have any of the following:
  • Todays Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • What is your Date of Birth?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have a current phone number?*
  • Format: (000) 000-0000.
  • Do you use / have an email address?
  • Where are you currently living?*
  • If you are admitted in a hospital or held in jail; when will you be released?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you have an emergency contact or someone we can call to reach you or who helps you?
  • Format: (000) 000-0000.

  • Health Status

    Recent Medical History and Treatment
  • Have you been diagnosed with a physical (body) condition?*
  • Have you been diagnosed with:
  • Have you been diagnosed with a mental health condition?*
  • Have you been diagnosed with:
  • Have you been in medical treatment within the last 3 months?*
  • Where or Who are you seeing or have seen recently for medical treatment
  • Are you currently taking any medication?*
    • Part I - Let's review your Medical Conditions 
    • You listed earlier that you have HEPATITIS; what type A, B, or C?

    • Hepatitis A*

      For individuals that have been diagnosed with Hepatitis A, the condition is highly contagious and face to face screenings will not be scheduled but rather phone or video screenings will be provided.
    • You stated earlier that you have VERTIGO; have you had the following
    • Part II - Now let's go over your Employment History 

    • Work Status

      Recent Employment History
    • What is your current Employment Status?

    • Currently Employed Full Time

      If you are currently working 35 hours or more in an occupation according to SSA disability requirements you must be unable to work for a minimum 12 month period. Working full time would technically disqualify SSA disability eligibility

    • Currently Employed Part Time

      If you are currently employed 35 hours or less depending on the type of work and the amount of monthly income made will directly affect SSA disability eligibility. Per SSA an applicant is expected to be unable to work for a minimum of 12 months or more.
    • Date Last Worked
       - -
      2 digit month, 2 digit day, 4 digit year
    • Part III - Lastly let's go over Social Security Benefits... 

    • SSA Filing Status

      Recent SSA Disability Activity
    • Have you filed for SSA (SSDI or SSI) Disability recently?*
    • When did you file?
       - -
      2 digit month, 2 digit day, 4 digit year
    • Date you became disabled?
       - -
      2 digit month, 2 digit day, 4 digit year
    • Do you have or have you ever had legal representation on a SSA claim (lawyer / advocate)?*
    • Have you EVER filed for SSA (SSDI or SSI) Disability in the past?*
    • Have you EVER received SSA (SSDI or SSI) Disability Benefits?*
  • Should be Empty: