Contact Us Form Test

Name *

Email *

Which of these best describes why you're getting in touch today? *

Please describe: *

Date of Birth *

Last four digits of Social Security Number *

What's the name of the organization you're having an issue with? *

If you have a main point of contact at the organization, please share it and any contact information you have.

Please briefly describe the issue you're having. *

Have you used the organization's grievance process or informed them of your issue another way? *

Do you know how to file a grievance with the organization? *

Phone number(s) you'd like added to your profile. (If it's a friend or family member's phone number, please include their name.)

Do you want to replace a previous phone number or add it as an alternative contact method?

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Add

Email address(es) you'd like added to your profile

Do you want to replace a previous email address or add it as an alternative contact method?

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Add

Use this form to sign up for the Adult SOAR Training Course for providers in the state of Texas.

First Name *

Phone Number *

Last Name *

Email *

Organization Name *

City *

Program Manager Name & Email *

Title *

County *

Supervisor Name & Email *

Are the SOAR services you provide connected to a program or department? *

Please provide the program or department information: *

How are SOAR applicants referred to you? *

Are you enrolling in this training for personal use or professional? *

Personal
Professional

How many individuals do you currently help apply for SSI/SSDI per year? *

After completing this training, how many individuals per year would you expect to help apply for SSI/SSDI using the SOAR model? *

By signing below, we acknowledge the expectation that the registrant will:

(1) Complete the SOAR Online Course Use the SOAR model to complete at least one SSI/SSDI application within 12 months

(2) Participate in ongoing SOAR related learning opportunities

(3) Use the key components of the SOAR process, including:
- Attending local training and other learning opportunities
- Maintaining communication with your SOAR Local Lead
- Submitting application data and outcomes using official tracking method required by the State Lead/Co-Lead
- Serve as the applicant’s SSA-1696 appointed representative and regularly communicate with SSA and DDS during the application process
- Complete applications for both Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI)
- Collect medical records from all providers who have treated the applicant, including an updated Mental Status Exam, for claims that include mental health diagnoses
- Write and submit a comprehensive FAST Medical Summary Report with each application, and, whenever possible, ensure that the FAST MSR is signed by an Acceptable Medical Source
- SOAR Case Workers first FAST MSR must be submitted to their local lead or state team lead/co-lead for review before their name is added on the active SOAR Representatives’ List within 12 months of taking the course.

For Austin/Travis County SOAR Representatives only:
- Full-time experience SOAR Representatives in Austin/Travis County must complete approximately 30 or more SOAR applications in 12 months.
- Non-experienced full-time SOAR Representatives in Austin/Travis County must approximately complete 25 or more in their first 12 months.
- SOAR Representatives that do not provide SOAR services as their primary position, must complete at least one application per year to remain active.

I understand and agree to the expectations above. *

I agree

Registrant Name *

Registrant Signature *

Date *

Supervisor Name *

Supervisor Signature *

Date *

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