SCES Money Management Client Referral

Money Management Client Referral

All information entered and submitted is HIPAA-compliant
Client name*

First NameLast Name
Client address*

Street Address

Apartment/Unit #

CityState

Zip Code
Homeowner?

YesNo
Client phone (home)

Area CodePhone Number
Client phone (mobile)
Please enter a valid phone number.
Client email
example@example.com
Client date of birth*

MonthDayYear
Date
Client Social Security #*
Client gender*

FemaleMaleOther
SAMS ID
Referral Type
What type of money management assistance would most benefit the client?*

Bill PayerRepresentative (Rep) PayeeDon't know
The Social Security Administration requires that we submit two forms in our application to be selected as Rep. Payee:

SSA-787: to be completed by a physician who has recently examined the client. Clinician must indicate that the feel a Rep Payee is necessary on pages 2 and 3

SSA-787 - Medical Source Opinion of Patient's Capability to Manage Benefits

SSA-827: authorization to disclose information to SSA, to be signed by client

SSA-827 - Authorization to Disclose Information to SSA

In order to expedite our application, please complete these forms and use the upload button below to submit with this referral.
Upload Documents

Cancelof
Per Massachusetts guidelines, Bill Payer clients must agree to have their bank statements sent to the SCES office for account monitoring purposes. Have you discussed this with the client? If not, please discuss this requirement with the client BEFORE submitting referral.

YesNo
Client Communication
Does client speak English?*

WellA littleNot at all
Primary language (if not English)
Referral Source
Referring source name*

First NameLast Name
Referring agency
Referring source phone*
Please enter a valid phone number.
Referring source email*
example@example.com
Relationship of referring source to client*
Client's case manager (if different than referring source)

First NameLast Name
Client's case manager phone number
Please enter a valid phone number.
Client's case manager email
example@example.com
Current Protective Arrangements
Indicate any existing protective arrangements

GuardianConservatorRep PayeePower of Attorney
Contact information
Client Income
Total monthly income*
Monthly income source(s) and amount(s)
SSA $0.00*
SSI $0.00*
SSDI $0.00*
MA SSP  $0.00*
Other   $0.00*
Client Personal Information
Marital status*

SingleMarriedWidowedDivorced
Birthplace: City* State* Country*
Mother's maiden name (required for Rep Payee)
Client physician name

First NameLast Name
Client physician phone
Please enter a valid phone number.
Living Information
Does client live alone?*

YesNo
How many people live In household?
Are others in household related to client?

YesNo
Would others in the household be able to assist a volunteer?

YesNo
Household member name(s)
Is client mostly homebound?*

YesNo
Medical Coverage
Client medical coverage (check all that apply)*

Medicare Part AMedicare Part BMedicare Part DMass HealthHMOMedigap policyOther insurance (please indicate below)
Other medical coverage details
Client Status
Why has the client been referred for money management assistance? Check all that apply*

Financial exploitationPhysical disability affecting bill payingMental disability affecting billing payingBills not paidLoss of prior bill payerMemory loss or confusionPaperwork piling upNeeds assistance reading and writingOverwhelmed or nervous over billBouncing checksDepletion of assetsWorrisome debt (provide detail below)Utility shut-off noticesInsufficient food/money at month's endThreat of evictionOther (please detail below)
Other referral reasons
Are there any behavioral or communication problems that could make the client inappropriate for volunteer assistance?*

Yes (please detail below)No
Behavior or communication problem details
In the past 2 years has the client received help from a social worker, psychologist, doctor or other mental health professional for stress, addictions, or an emotional or nervous problem?*

Yes (please detail below)No
Mental health details
Who is paying the client's bills now?*
What method of bill payments are used?

ChecksOnline/auto-paymentsCash/money orders
Have you discussed the program with the client?*

YesNo
Is the client agreeable to participating in the program? (reminder: Bill Payer clients must agree to have their bank statements mailed directly to SCES for monitoring)*

YesNo
Is the client capable of understanding why s/he is being referred?*

YesNo
Does the client smoke?*

YesNoDon't know
Does the client have pets?*

Yes (please detail below)NoDon't know
What kind of pets?
Does the client have a checking account?

Yes (please indicate bank below)No
Client bank name
To the best of your knowledge, is the client’s annual income below $55,950?*

YesNoDon't know
To the best of your knowledge, are the client’s liquid assets below $55,950*

YesNoDon't know
Should be Empty:

Money Management Client Referral

Referral Type

Client Communication

Referral Source

Current Protective Arrangements

Client Income

Client Personal Information

Living Information

Medical Coverage

Client Status