SOAR Outreach Referral
Client Name:
Gender:
DOB:
M
F
Race:
Social Security Number:
Contact information (phone number and address):
1. Have you had at least 3 interactions with individual?
YES
NO
2. Is individual homeless or at risk of homelessness?
YES
NO
3. Is individual connected to case management services?
If YES, where:
YES
NO
4. Additional locations individual frequents?
Point of contact:
5. Date of next visit? ___________________________________________________________
8. Did individual consent to allow SOAR outreach worker to attend?
YES
NO
9. Is individual receiving any income or other public benefits (Please circle all that apply)?
TCA
TDAP
SSI/SSDI
FOOD STAMPS
OTHER: ___________________________________________________________________
10. Does individual have insurance? PAC
MA
MEDICARE
PRIVATE
OTHER
NO
11. Psychiatric symptoms and/or diagnosis: __________________________________________
RETURN OR FAX: ATTENTION Kathryn Craige at 410-632-0065
Referring Agency: ______________________________________________________________
Referral by: ___________________________________________________________________
Contact information:
Office use only: Date received: ________________________
Circle one:
Approved
Denied
Decision date: ________________
Protective Filing Date: ___________________________
Initials: _______
Revised 5.14.13
SOAR Applicant Checklist
REQUIRED:



Individual is experiencing homelessness (street, shelter, transitional housing, doubling up) or at
risk of homelessness
Individual is diagnosed with a mental illness by a psychiatrist or psychologist (an Axis I or Axis
II disorder)
Individual is diagnosed with a Priority Population Diagnosis, established by the Mental Hygiene
Administration
 295.10 Schizophrenia, Disorganized Type
 295.20 Schizophrenia, Catatonic Type
 295.30 Schizophrenia, Paranoid Type
 295.40 Schizophreniform Disorder
 295.60 Schizophrenia, Residual Type
 295.70 Schizoaffective Disorder
 295.90 Schizophrenia, Undifferentiated Type
 296.33 Major Depressive Disorder, Recurrent, Severe Without Psychotic Features
 296.34 Major Depressive Disorder, Recurrent, Severe With Psychotic Features
 297.1 Delusional Disorder
 298.9 Psychotic Disorder, NOS
 301.22 Schizotypal Personality Dosorder
 301.83 Borderline Personality Disorder
 296.43 Bipolar I Disorder, Most Recent Episode, Manic, Severe Without Psychotic Features
 296.44 Bipolar I Disorder, Most Recent Episode, Manic, Severe With Psychotic Features
 296.53 Bipolar I Disorder, Most Recent Episode, Depressed, Severe Without Psychotic
Features
 296.54 Bipolar I Disorder, Most Recent Episode, Depressed, Severe With Psychotic Features
 296.63 Bipolar I Disorder, Most Recent Episode, Mixed, Severe Without Psychotic Features
 296.64 Bipolar I Disorder, Most Recent Episode, Mixed, Severe With Psychotic Features
 296.80 Bipolar Disorder, NOS
 296.89 Bipolar II Disorder

Individual is at least 18 years old

Individual is not working due to psychiatric conditions

Individual is currently exhibiting symptoms of mental illness or has periods with worsening of
symptoms that prevents sustainable employment. For example,
 Psychotic Symptoms (positive or negative)
 Depressive Symptoms (decreased energy, lack of motivation, suicide attempts)
 Manic Symptoms (racing thoughts, disorganized thoughts)
 Anxious feelings (paranoia, nervousness)
 Cognitive deficits (brain injury; problems with concentration, memory, etc.)
 Other: ___________________________________________________________________

Individual exhibits functional impairments in three out of the following four areas:
 Activities of Daily Living
 Social Functioning
 Concentration, Persistence and Pace
 Decompensation (at least 3 times a year for periods lasting at least 2 weeks)
RECOMMENDED:




Individual is prescribed psychiatric medications and continues to experience symptoms
Individual has medical evidence (for – at least part of – the past 12 months) that corroborates
mental illness and medical complaints. If no medical evidence or large gaps in treatment,
 Individual clearly exhibiting symptoms severe enough that a one time examination by a
physician would demonstrate issues
 Can write a medical summary report that details symptoms and functional impairments that
demonstrates diagnosed disability
Individual is not working due to medical and/or psychiatric conditions (i.e. not because cannot
find work or was laid off)
 History of failed work attempts (started and stopped employment due to diagnosed disability)
 Long work history, but can no longer work up to SGA due to conditions
 Scattered work history due to conditions and other factors
Documented poor work history to include:
 History of failed work attempts
 Long work history, but can no longer work
SOAR PROJECT
(SSI/SSDI Outreach, Access, and Recovery)
Consent for Release of Information
Sign this form only if you want the Social Security Administration to give information or
records about you to _____________________________(service provider).
Local SSA Office___________
TO: Social Security Administration fax:
Customer’s Name______________________________________________________
Date of Birth_____________ Social Security Number_________________________
THIS SECTION TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION
____No Record
____Supplemental Security Income
____Terminated Record
____Social Security Disability Income
__________ SSI
Date Terminated _____________
MMDDYY
Current Claim Status
____
____
SSI Claim Pending:
____ SSDI Claim Pending:
Initial Claim
Date Filed ________
Initial Claim
Date Filed ________
Reconsideration
Date Filed ________
Reconsideration
Date Filed ________
Hearing Level
Date Filed ________
Hearing Level
Date Filed ________
SSI Claim Denied:
____
SSDI Claim Denied:
Initial Claim
Date Denied ________
Initial Claim
Date Denied ________
Reconsideration
Date Denied ________
Reconsideration
Date Denied ________
Hearing Level
Date Denied ________
Hearing Level
Date Denied ________
(Circle One)
Denial Reason: Medical Non-Medical Other
Other
Denial Reason: Medical Non-Medical
_______________________________________________________________________________
Allowance
____ SSI: Eligibility date __________
_____ SSDI: Eligibility date _________
SSA Claims information was provided by: ________________________________________
(SSA Liaison)
Date of Response __________________
Protective Filing Date________________________
Telephone Number: _____________________
SSA Field Office Code: _____________________
Service Provider _____________________________________________________
Name of Staff and phone #
(Please Print)
Agency Name
Customer’s Name ______________________________________________________________
Date of Birth _________________ Social Security Number____________________________
I authorize SSA to release the dates and status of my Social Security Disability Insurance and/or
Supplemental Security Income application(s), to:
_________________________________
(Service Provider)
_______________________________________
(fax #)
This consent for release of information is in effect from __________ to __________ (not to exceed 1
year).
(MMDDYY)
(MMDDYY)
I want this information released because I am pursuing entitlement to Social Security disability
programs.
I am the individual to whom the information/record applies or that person's parent (if a minor) or legal
guardian. I declare under penalty of perjury that I have examined all the information that I provided on
this form and that it is true and correct to the best of my knowledge. I understand that anyone who
knowingly gives a false or misleading statement about a material fact in this information, or causes
someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
Signature: __________________________________ Relationship: ________________
(Below, show signatures, names, and addresses of two people if signed by mark.)
Date: _______________
Witness #1
Witness #2
________________________
______________________
(Print Name)
________________________
(Signature)
________________________
(Address)
________________________
(City, State, and Zip code)
(Print Name)
______________________
(Signature)
______________________
(Address)
______________________
(City. State, and Zip code)