SCES Money Management Client Referral

Money Management Client Referral

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

First Name Last Name
Client address *

Street Address

Apartment/Unit #

City State

Zip Code
Homeowner?

Yes No
Client phone (home)
Please enter a valid phone number.
Client phone (mobile)
Please enter a valid phone number.
Client email
example@example.com
Client date of birth *

Month Day Year
Date
Client Social Security # *
Client gender *

Female Male Other
Referral Type
What type of money management assistance would most benefit the client? *

Bill Payer Representative (Rep) Payee Don'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

Cancel of
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.

Yes No
Client Communication
Does client speak English? *

Well A little Not at all
Primary language (if not English)
Referral Source
Referring source name *

First Name Last 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 Name Last 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

Guardian Conservator Rep Payee Power 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 *

Single Married Widowed Divorced
Birthplace: City * State * Country *
Mother's maiden name (required for Rep Payee)
Client physician name

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

Yes No
How many people live In household?
Are others in household related to client?

Yes No
Would others in the household be able to assist a volunteer?

Yes No
Household member name(s)
Is client mostly homebound? *

Yes No
Medical Coverage
Client medical coverage (check all that apply)

Medicare Part A Medicare Part B Medicare Part D Mass Health HMO Medigap policy Other 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 exploitation Physical disability affecting bill paying Mental disability affecting billing paying Bills not paid Loss of prior bill payer Memory loss or confusion Paperwork piling up Needs assistance reading and writing Overwhelmed or nervous over bill Bouncing checks Depletion of assets Worrisome debt (provide detail below) Utility shut-off notices Insufficient food/money at month's end Threat of eviction Other (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?

Checks Online/auto-payments Cash/money orders
Have you discussed the program with the client? *

Yes No
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) *

Yes No
Is the client capable of understanding why s/he is being referred? *

Yes No
Does the client smoke? *

Yes No Don't know
Does the client have pets? *

Yes (please detail below) No Don'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? *

Yes No Don't know
To the best of your knowledge, are the client’s liquid assets below $55,950 *

Yes No Don'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