SSI/SSDI Prescreen Tool

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Offering simple, integrative techniques using meditative mind, body, and movement interventions to reduce stress and anxiety, enhance focus, and balance emotions. Our goal is to help you build resilience and improve your overall well-being.

A Program of Providence Family Life Center.

Are you interested in applying for SSI/SSDI Benefits?
Take a few minutes to complete the brief questionnaire and a member of our team will contact you to schedule an appointment within 24- 48 hours.

SSI/SSDI Prescreener Tool

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Phone

You maybe eligible for SSI/SSDI if you meet 3 or more of the following criteria: *

Past hospitalization against the person’s will and/or current mental health treatment(at least 12 mos of recent treatment history)

Self-report of multiple physical health conditions or observations of serious health conditions

Tri-morbidity (co-occurring mental and substance use disorder with a chronic medical condition)

Observations of poor hygiene or living skills

History of serious brain injury or head trauma

Difficulty in concentrating and remembering things

Self-reported disability or diagnoses information

Experiencing homelessness or at risk for homelessness

Have a history of incarceration

Unable to work due to the conditions selected above

Please explain why you think you are eligible:

Have you applied for SSI/SSDI benefits in the last 60 days and reeived a denial? Please also let us know if you are working with an attorney.

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!