SOCIAL SECURITY INTAKE SHEET

The Slayton Group, LLC - The Disability Experts!  An Advocate for the Disabled because Your Health is Worth the Fightl We turn Your "NO" into OUR YES!!

Thank you for choosing TSG to represent you in obtaining your social security disability benefits.

Below you will find our intake form for completion. Once completed, you will be contacted by our office for your FREE consultation and case evaluation.

Time is of the essence - Start TODAY by filling out the form below.

Case Evaluation Team
INTAKE SHEET

For Social Security Disability Claims
Name*

NameLast Name First
Middle Name
Date of Birth*

MonthDayYear
Date
Place of Birth (City, State)*
Country
Social Security Number*
Drivers License or State ID Number*
State Issued License*
Your Current Address*
Apt
City*
State*
Zip*
County
Primary Contact Number*
Secondary Number*
Mother's Maiden Name*
EMail Address
example@example.com
I authorize emails as a form of communication for my case from The Slayton Group, LLC
Marital Status*
Spouses Name
Do you have a history of alcohol or drug use?*
Do you currently have a disability claim pending?*
What date did you apply for disability benefits

MonthDayYear
Date
What date did you become disabled*

MonthDayYear
Date
What date did you last work*

MonthDayYear
Date
What was your job
What date is the date of your most recent denial?

MonthDayYear
Date
Do you know what level of appeal your case is on?
Did you apply for both DIB and SSI or only one?
What is your highest level of education?
Any vocational training or certifications
What type of work have you done for the last 5 years (2025)
What type of work have you done for the last 5 years (2024)
What type of work have you done for the last 5 years (2023)
What type of work have you done for the last 5 years (2022)
What type of work have you done for the last 5 years (2021)
What type of work have you done for the last 5 years (2020)
Did you receive any workman's compensation benefits or short term/long term disability?*
Date payments began?

MonthDayYear
Date
How much per month?
What are your impairments or your diagnosis
Symptoms (List all)
Which doctors have treated you and are treating you for your disability (List all)
List all tresting sources
What prescribed medications are you taking? (List all)
List all tresting sources
Are you currently receiving treatment?*
Do you currently have a Will?
Social Media
How did you hear about The Slayton Group?
Secondary Contact Person*

NameLast Name First
Phone Number
Other
Thank you for contacting The Slayton Group, LLC - one of our Disability Experts will be contacting shortly for a FREE consultation regarding your claim and to discuss the be possible plan in order for you to be approved for disability.

Your Health is Worth the Fight!

1-833-599-0098
Should be Empty: