SSI/SSDI PRESCREEN

Please complete the form
below to schedule a prescreen interview to see if you meet criteria to apply.

First Name

Email

Last Name

Date of Birth

Phone

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

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

Have a history of incarceration

Unable to work due to the conditions selected above

Child with IEP or 504 plan

Please explain why you think you are eligible:

Please tell us about your work history?

Initials

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

Thanks for submitting! A member of our team will respond to you within 2 - 3 business days. Our office hours are Monday through Thursday 9am - 3pm by appointment only.

2396763159

Providence Family Life Center (PFLC) is a fully licensed & bonded, IRS 501(c)(3) charitable organization.