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Request for Case Evaluation
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Age
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How did you hear about our office?
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Please tell us about your issue. What kind of help are you looking for?
For assistance with disability claims: please provide details regarding work status, diagnosed conditions, and medical treatment.
Do you currently have an attorney representing you?
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No
Yes for this matter.
Yes for another matter.
Previously for this matter.
Please attach any recent decisions or records that will help us review your matter.
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Disability Case Evaluation Questionnaire
Disability Claim Status
You completed a request for a free case evaluation for disability benefits, please describe why you’re seeking assistance with your case.
PLEASE BE AS DETAILED AS POSSIBLE HERE. I NEED TO KNOW WHAT'S GOING ON WITH THEM AND WHY THEY BELIEVE THEY ARE DISABLED.
What Is the Status of Your Disability Application?
*
Need to File an Application
Initial Application Pending
Initial Application Denied (requires reconsideration appeal)
Reconsideration Denied (requires a request for hearing appeal)
Already appealed and waiting for a hearing
Denied by Social Security Judge
I am not sure
Do You Have Any Related Cases Pending or Recently Resolved?
*
Long-term disability under a private policy
Workers' compensation benefits
Unemployment benefits
Accident case (ex: car accident, slip and fall, etc)
Social Security retirement
Claim against employer (ex: discrimination)
Other retirement benefits
Other
Do you currently owe Social Security any money (an “overpayment”)?
*
Please Select
No, I do not owe SSA anything
Yes, I owe SSA money (please explain below)
This means SSA says you were paid too much in the past and you must pay it back.
You answered that you owe Social Security for an overpayment - how much do you owe, and what is the status of that overpayment?
Employment and Work History
When was your last day of work? (approximately if unsure)
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Month
-
Day
Year
Date
What kind of work have you done in the last 5 years?
Include approximate dates and job duties
Are you currently working? (this includes part-time, gig, or under-the-table work)
No - Not working
Yes - Full-time
Yes - Part-time
You answered that you are currently working - please explain your job, hours, and pay.
In the past 6 months, have you earned more than $1,620/month before taxes (even for one month)?
No, I did not earn over $1,620 in any month
Yes
You answered that you earned over $1,620 in at least one month over the last 6 - please explain when and how much you earned.
Is Your Health Insurance Through Medicaid (the state) or Another Source (e.g., Spouse)?
Medical Status
Do You Currently Have Health Insurance?
Yes
No
Not yet but I applied and my application is pending.
What Medical Conditions Are Keeping You From Working? (select all that apply)
*
Neck or back condition
Joint condition
Vision loss
Hearing loss
Breathing disorder
Sleep disorders
Heart condition
Stomach or liver condition
Blood disorder
Skin condition
Endocrine conditions including diabetes and thyroid conditions
Neurological conditions including seizures, stroke, MS, and TBIs
Autoimmune condition including inflammatory arthritis, lupus, and fibromyalgia
Cancer
Cognitive disorders
Learning disorders
Autism spectrum disorders
Depressive disorders
Bipolar disorder
Anxiety disorders
Schizophrenia spectrum and psychotic disorders
Trauma disorders (ex: PTSD)
Eating disorders
Other
Please Identify Your Medical Providers (select all that apply)
*
Primary Care Doctor
Specialist Doctor (including surgeon)
Pain Management Doctor
Physical Therapist
Psychiatrist
Psychotherapist
Other Medical Provider
Please describe your symptoms and limitations.
What limitations impact your ability to work?
List Current Medications
Family and Living Arrangements
Do You Have Minor Children?
Yes
No
If Yes, What Are Their Ages?
Do You Live With Any Other Household Members?
Yes
No
If Yes, Please Describe (other household members - i.e. spouse, parents)
Is There Anything Else You Would Like Us to Know About Your Case?
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