Social Security Benefits (SSI/SSDI/CAPI) Adult/Child Referral Form

Thank you for the Social Security Benefits adult/child referral. Please complete as much information as available.

Candidate Name

Candidate Email

Referring Agency

Staff Contact Number

Today's Date

Candidate Phone

Person Making Referral

Staff Email Address

Candidate Identifying Information:

Is the Candidate A Child? For a child to be eligible, he/she must be under the age of 18 (19 if a full-time student)

Yes

Date of Birth

Age

US Citizen (Yes/No)

Emergency/Parent or Legal Guardian Name

Gender

City & State of Birth

(If No) Immigration Status?

Emergancy Contact/Parent or Legal Guardian Phone Number

Emergency Contact/Parent or Legal Guardian Address

Current Living Arrangement (address, location)

Is the Candidate Housed?

Yes

Comments:

Has The Candidate Recently Applied For Social Security Benefits?

Yes

IF Yes. Application Date:

Decision Date:

Decision:

If application was denied. Did you appeal?

If Yes. Are you waiting on decision?

Are they working with a lawyer?

To assess SSI/SSDI 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 ($1,310 per month in 2021) due to medical and/or psychiatric conditions (not because they cannot find work or were laid off)
Impairments in functioning due to medical and/or psychiatric conditions
Once you submit this form we will contact the client within 24 hours and also provide you with an email confirming our follow-up
Thank you for referring this client to our expert Benefits Access Support service.

Thanks for submitting!