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

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

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)

Part A: Housing Assessment

Is the Candidate Housed?

Part B: Current Application for SSA Benefits or Pending Appeal?

Has The Candidate Recently Applied For Social Security Benefits?

Summary and Next Steps

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!

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