Child's SSI Inquiry
Please complete this form prior to your consultation with Impact Disability Law. We look forward to helping you!
Child's Name:
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First Name
Last Name
Child's Date of Birth:
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-
Month
-
Day
Year
Date
Your Name:
*
First Name
Last Name
Relationship to the Child:
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Is this child current receiving SSI?
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Yes
No
If applicable, provide a brief description of your child's physical challenges?
*
If applicable, provide a brief description of your child's mental challenges?
*
How is your child doing academically?
*
What medical providers does your child currently treat with?
*
What medications is your child currently taking?
*
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