SOAR Outreach Referral



SOAR Referral

Client Name: Date:

Gender: M F Race:

Social Security Number: DOB:

Contact information (phone number and address):

1. Who is the treating/diagnosing psychiatrist? ______________________________________

2. Location of client’s mental health treatment?______________________________________

3. Is individual homeless or at risk of homelessness? YES NO

4. Is individual connected to case management services? YES NO

If YES, where:

5. Current SSI/SSDI status (Check one):

_____ Nothing pending (not filed or denied in past)

_____Application pending (circle one): Applied Appealed Hearing Date: __________

_____Recently denied Date: _________________

_____Unknown

6. Is individual receiving any income or other public benefits (Please circle all that apply)?

TCA TDAP SSI/SSDI FOOD STAMPS

OTHER: ___________________________________________________________________

9. Does individual have insurance? PAC MA MEDICARE PRIVATE OTHER NO

10. Psychiatric symptoms and/or diagnosis: __________________________________________

RETURN OR FAX: ATTENTION Worcester County Core Service Agency at 410-632-0065

Referring Agency: ______________________________________________________________

Referral by: ___________________________________________________________________

Contact information:

Office use only: Date received: ________________________

Circle one: Approved Denied Decision date: ________________ Initials: _______

Protective Filing Date: ___________________________ Revised 7.12.13

SOAR Applicant Checklist

REQUIRED:

□ Individual is diagnosed with a Priority Population Diagnosis, established by the Mental Hygiene Administration, by a psychiatrist:

□ 295.10 Schizophrenia, Disorganized Type

□ 295.20 Schizophrenia, Catatonic Type

□ 295.30 Schizophrenia, Paranoid Type

□ 295.40 Schizophreniform Disorder

□ 295.60 Schizophrenia, Residual Type

□ 295.70 Schizoaffective Disorder

□ 295.90 Schizophrenia, Undifferentiated Type

□ 296.33 Major Depressive Disorder, Recurrent, Severe Without Psychotic Features

□ 296.34 Major Depressive Disorder, Recurrent, Severe With Psychotic Features

□ 297.1 Delusional Disorder

□ 298.9 Psychotic Disorder, NOS

□ 301.22 Schizotypal Personality Dosorder

□ 301.83 Borderline Personality Disorder

□ 296.43 Bipolar I Disorder, Most Recent Episode, Manic, Severe Without Psychotic Features

□ 296.44 Bipolar I Disorder, Most Recent Episode, Manic, Severe With Psychotic Features

□ 296.53 Bipolar I Disorder, Most Recent Episode, Depressed, Severe Without Psychotic Features

□ 296.54 Bipolar I Disorder, Most Recent Episode, Depressed, Severe With Psychotic Features

□ 296.63 Bipolar I Disorder, Most Recent Episode, Mixed, Severe Without Psychotic Features

□ 296.64 Bipolar I Disorder, Most Recent Episode, Mixed, Severe With Psychotic Features

□ 296.80 Bipolar Disorder, NOS

□ 296.89 Bipolar II Disorder

□ Individual is at least 18 years old

□ Individual is not working due to psychiatric conditions

□ Individual is currently exhibiting symptoms of mental illness or has periods with worsening of symptoms that prevents sustainable employment.

|Depression/Bipolar |Psychotic d/o |Anxiety (trauma) – |Cognitive – |

|At least 4: |At least 1: |At least 1: |At least 1: |

|Difficulties falling or staying asleep |See things others say they don’t see |Being easily startled |Forgetting names, appointment, |

|Changes in appetite |Hear things others say they don’t hear |Discomfort with/fear of people being |etc. with a need for frequent |

|Loss of interest in things you used to enjoy |Feel as though others are looking at or|behind you |reminders |

|Decreased energy that makes activities difficult|talking about you |Restlessness or nervousness |Difficulties remembering past |

|Feelings of worthlessness or guilt |Feel as though others are watching you |Panic attacks |events in your life |

|Trouble staying focused |or want to hurt you |Constant feeling of being “on guard” |Difficulties reading, writing, or|

|Thoughts of hurting yourself or others |Do you observe: | |speaking |

|Mania – at least 3 |Flat or inappropriate affect |Fear that causes you to avoid a | |

|Feelings of extreme energy |Blunted speech |particular activity, place, or object |Trouble understanding |

|A decreased need for sleep |Restricted emotions |Obsession over something that you must|instructions |

|Racing thoughts that make focusing more |Responding to external stimuli |respond to | |

|difficult | |Nightmares or recurrent thoughts of a | |

|Feeling superior to others | |traumatic experience | |

|Feelings that you can accomplish many tasks | | | |

|A spending spree you can’t afford | | | |

|Any risky behaviors without worrying for | | | |

|consequences | | | |

|Impulsivity | | | |

□ Individual exhibits functional impairments in three out of the following four areas:

|Activities of daily living |Social functioning |Concentration, Persistence, or Pace |Decompensation |

|Hygiene activities |Lack contact with family |Difficulty focusing on one task |History of hospitalizations |

|Cleaning (without prompts) |History of poor interpersonal relationships |Jumping from task-to-task |History of incarcerations |

|Trouble getting out of bed |Isolating behaviors |Difficulty completing a task |History of medication changes |

|Lack desire to cook |History of conflicts |History of starting but not completing a |Treatment plan changes |

|Trouble grocery shopping |Lack of participation in groups |task |Disengagement from treatment |

|Trouble doing laundry |Poor co-worker/supervisor relationships |Short term memory deficits (appt, etc.) |when more symptomatic |

|Anxiety or confusion riding public |Anxiety in social settings |Long term memory deficits | |

|transportation |Fears that others are targeting |Easily distracted and require redirection | |

|Trouble budgeting | |Require reminders to complete tasks | |

□ Individual is not working due to medical and/or psychiatric conditions (i.e. not because cannot find work or was laid off)

□ History of failed work attempts (started and stopped employment due to diagnosed disability)

□ Long work history, but can no longer work up to SGA due to conditions

□ Scattered work history due to conditions and other factors

□ Inability to focus on job tasks

SOAR PROJECT

(SSI/SSDI Outreach, Access, and Recovery)

Consent for Release of Information

Sign this form only if you want the Social Security Administration to give information or records about you to Worcester County Core Service Agency (service provider).

TO: Social Security Administration fax: Local SSA Office___________

Customer’s Name______________________________________________________

Date of Birth_____________ Social Security Number_________________________

THIS SECTION TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION

____No Record ____Supplemental Security Income ____Social Security Disability Income

____Terminated Record __________ SSI Date Terminated _____________

MMDDYY

Current Claim Status

____ SSI Claim Pending: ____ SSDI Claim Pending:

Initial Claim Date Filed ________ Initial Claim Date Filed ________

Reconsideration Date Filed ________ Reconsideration Date Filed ________

Hearing Level Date Filed ________ Hearing Level Date Filed ________

____ SSI Claim Denied: ____ SSDI Claim Denied:

Initial Claim Date Denied ________ Initial Claim Date Denied ________

Reconsideration Date Denied ________ Reconsideration Date Denied ________

Hearing Level Date Denied ________ Hearing Level Date Denied ________

(Circle One)

Denial Reason: Medical Non-Medical Other Denial Reason: Medical Non-Medical

Other _______________________________________________________________________________

Allowance

____ SSI: Eligibility date __________ _____ SSDI: Eligibility date _________

SSA Claims information was provided by: ________________________________________

(SSA Liaison)

Date of Response __________________ Protective Filing Date________________________

Telephone Number: _____________________ SSA Field Office Code: _____________________

Service Provider: Kathy Craige 410-632-1100 ext. 1047 Worcester County CSA

Name of Staff and phone # (Please Print) Agency Name

Customer’s Name ______________________________________________________________

Date of Birth _________________ Social Security Number____________________________

I authorize SSA to release the dates and status of my Social Security Disability Insurance and/or Supplemental Security Income application(s), to:

_________________________________ _______________________________________

(Service Provider) (fax #)

This consent for release of information is in effect from __________ to __________ (not to exceed 1 year). (MMDDYY) (MMDDYY)

I want this information released because I am pursuing entitlement to Social Security disability programs.

I am the individual to whom the information/record applies or that person's parent (if a minor) or legal guardian. I declare under penalty of perjury that I have examined all the information that I provided on this form and that it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

Signature: __________________________________ Relationship: ________________

(Below, show signatures, names, and addresses of two people if signed by mark.)

Date: _______________

Witness #1 Witness #2

________________________ ______________________

(Print Name) (Print Name)

________________________ ______________________

(Signature) (Signature)

________________________ ______________________

(Address) (Address)

________________________ ______________________

(City, State, and Zip code) (City. State, and Zip code)

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