Adult Client Referral Form

Candidate Identifying Information:

(must be within 30 days of 18 years of age, or within 180 days if exiting foster care)

Part A: Housing Assessment

Is the Candidate Housed?
Is the Candidate In An Institution?
If yes, Select:

Part B: Employment History:

(Reverse Chronological Order) 

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

Has The Candidate Recently Applied For Social Security Benefits?

Part D: Diagnostic Information:

Please list all mental and physical health diagnoses:

Received Treatment for Conditions at the following Facilities:

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 ($1,260/month in 2020) 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


(562) 612-5001

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The MSC 1301 W. 12th Street, Long Beach, CA 90813

PO Box 32861, Long Beach, CA 90831

© All rights reserved Help Me Help You

This organization is an equal opportunity provider and employer. 


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