Adult Client Referral Form

Candidate Name

Candidate Email

Referring Agency

Staff Contact Number

Date of Referral

Candidate Phone

Person Making Referral

Staff Email Address

Candidate Identifying Information:

Date of Birth

Age

Gender

City & State of Birth

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

SSN:

Race

Marital Satus

US Citizen (Yes/No)

(If No) Immigration Status

Current Living Arrangement (address, location)

High School Name/City

Grade Completed

List all Income Sources

Income Ammounts

Emergency Name

Emergancy Contact Number

Part A: Housing Assessment

Is the Candidate Housed?

Yes

Is the Candidate In An Institution?

Yes

If yes, Select:

Jail

Prison

If Prison, Provide the CDCR#:

Comments

Part B: Employment History:

(Reverse Chronological Order)

1. Employer

Start Date

Title:

End Date

2. Employer

Start Date

Title:

3. Employer

End Date

Start Date

Title:

End Date

4. Employer

Start Date

Title:

End Date

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

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?

Part D: Diagnostic Information:

Please list all mental and physical health diagnoses:

Mental

Physical

Received Treatment for Conditions at the following Facilities:

1. Treatment

Date

Contact Number

2. Treatment

Date

Contact Number

3. Treatment

4. Treatment

Date

Contact Number

Date

Contact Number

Additional Comments

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

Thanks for submitting!