Disability Prescreener

Date

First name

Last name

Birthday

Email

Number

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

Have at least 6 to 12 months of consistent care by a physician or specialist

Difficulty in concentrating and remembering things

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)

Unable to manage hygiene or living skills

Experiencing homelessness or at risk for homelessness

History of serious brain injury or head trauma

Unable to work due to the conditions selected above

Child with IEP or 504 plan

Tell Us About Your Work History

Check here if you have applied and have been denied in the past

Check here if you are working with an attorney