SOAR Outreach Referral
Client Name: DOB:
Gender: 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? YES NO
If YES, where:
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:
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