Child Client Referral Form

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Child's Identifying Information:

Part A: Address and Living Arrangement

Is the child/family homeless?
With whom is the child living? Check the appropriate selection
If in a hospital, treatment, or juvenile detention facility are they expected to be released within 30 days?
Were they experiencing homelessness before entering the facility?

Part B: Current or Past Applications for SSI

Has the child previously applied for Supplemental Security Income (SSI)?
What was the decision on the application?
Is the child working with a lawyer?
Did the child appeal?
If yes, are they waiting on a decision?

Part C: Income and Resources

Is the child working and earning over $1,220/month (substantial gainful activity for 2019)?
Using the chart in Section F, does the family’s estimated monthly income fall within the eligibility guidelines for SSI?

Part D: Diagnostic Information:

Please list all mental and physical health diagnoses:

Does the child have an Individualized Education Program (IEP) or are they receiving special education services at school?
Does the child have a history of substance use or addiction?
If yes, has the child received treatment for substance use or addiction?

Prior or current substance use is not a disqualifying factor for SSI or assistance from a SOAR provider

Part E: Narrative questions for SOAR eligibility

Ask these questions to the candidate and record answers

Section F: Income Chart, Summary, and Next Steps

Income Deeming for Children

If a child is under age 18, not married, and lives at home with parent(s) who do not receive SSI benefits, SSA may consider a portion of the parents' income and resources as if they were available to the child. They may also count a portion of a stepparent’s income and resources if the child lives with both a parent and a stepparent (or an adoptive parent and a stepparent). This also occurs when a child is temporarily away at school, returns home during weekends, holidays or during the summer and remains subject to parental control. SSA calls this process "deeming." SSA makes deductions from deemed income for parents and for other children living in the home. After subtracting these deductions, SSA uses the remaining amount to decide if the child meets the SSI income and resource requirements for a monthly benefit.


Deeming Eligibility Chart for Children for 2019

The chart below gives the highest amount of gross monthly income for this year (before taxes are withheld) that a parent(s) can earn or receive and still have a child qualify for SSI. Note that SSA does not count some types of income that a parent may receive; for example, money received for providing foster care to an ineligible child.


Summary and Next Steps

To assess SSI eligibility for children (ages 0-17) we are looking for basic information on:

  • The presence of medical and/or psychiatric conditions or symptoms (including emotional and learning problems) that would fit an SSA listing

  • How the conditions have lasted or are expected to last at least 12 months, or end in death

  • The ways in which the conditions limit the child’s ability to function in the home, school and community, as compared to children of the same age who do not have impairments

  • How the child and/or parent/guardian fits the income and resource requirements for SSI eligibility

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