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3. SOAR Referral
5. Client Information
7. Name*
8. D.O.B.*
10. Gender*

    1. M
    2. F
    3. Other
11. Race
12. Ethnicity
13. Veteran*

    1. Yes
    2. No
15. Address1
17. Address2
19. City
20. State
21. Zip
23. Phone Number*
24. Alternative Contact Name and Number*
26. 1. Is the Individual homeless or at risk of homelessness?*

    1. Yes

    1. No
28. 2. Is individual connected to case management and/or other supportive services*

    1. Yes

    1. No
29. If Yes, Where?
31. 3. Is individual receiving any income or other public benefits (Please circle all that apply)?

    1. Food Stamps
    2. SSI/SSDI

    1. TDAP
    2. TCA
32. Other:
34. 4. Psychiatric diagnosis and/or symptoms:*
36. 5. Does individual have a psychiatrist and/or therapist?*

    1. Yes

    1. No
37. If Yes, Where?
39. Provider Information
41. Referring Agency:*
43. Referral By:*
44. Contact Number:*
46. 1. Have you had at least 3 interactions with individual?*

    1. Yes

    1. No
47. 2. Date of next visit?*
    2. Date of next visit?
49. 3. Does individual consent to allow SOAR worker to attend?*

    1. Yes

    1. No
50. Additional Information:
53. SOAR Applicant Checklist
55. Required:

    1. Individual is experiencing homelessness (street, shelter, transitional housing, doubling up) or at risk of homelessness
57. 1. Individual is diagnosed with a mental illness by a psychiatrist or psychologist (an Axis I or Axis II disorder)
58. 1. Individual is at least 18 years old
60. 1. Individual is currently exhibiting symptoms of mental illness or has periods with worsening of symptoms that prevents sustainable employment. For example, →
61. Examples

    1. Psychotic Symptoms (positive or negative)
    2. Depressive Symptoms (decreased energy, lack of motivation, suicide attempts)
    3. Manic Symptoms (racing thoughts, disorganized thoughts)
    4. Anxious feelings (paranoia, nervousness)
    5. Cognitive deficits (brain injury; problems with concentration, memory, etc.)
    6. Other
63. 1. Individual exhibits functional impairments in three out of the following four areas:
64. Areas

    1. Activities of Daily Living
    2. Social Functioning
    3. Concentration, Persistence and Pace
    4. Decompensation (at least 3 times a year for periods lasting at least 2 weeks)
66. Recommended:

    1. Individual is prescribed psychiatric medications and continues to experience symptoms
68. 1. 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, →
69. 1. Individual clearly exhibiting symptoms severe enough that a one time examination by a physician would demonstrate issues
    2. Can write a medical summary report that details symptoms and functional impairments that demonstrates diagnosed disability
71. 1. Individual is not working due to medical and/or psychiatric conditions (i.e. not because cannot find work or was laid off) →
72. 1. History of failed work attempts (started and stopped employment due to diagnosed disability)
    2. Long work history, but can no longer work up to SGA due to conditions
    3. Scattered work history due to conditions and other factors
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74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

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