Request for Case Evaluation

Request for Case Evaluation
Name

First NameLast Name
Email
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Phone Number
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Consent to Texting
Contact Preference
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City of Residence
State of Residence
Age
Date of Birth

MonthDayYear
Date
How did you hear about our office?
Referral Name:

First NameLast Name
Please tell us more about how you heard about our office (you answered "other" above).
Referred by:
Person Completing Form:

First NameLast Name
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?
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. Tell me why you reached out for a disability case evaluation. I need to know: (1) What’s happening with your health including specific diagnoses and how it affects your ability to work, and (2) What kind of help you’re looking for right now. For example, are you hoping for full representation with your case, legal advice on your options, or just information about the process? The more specific you are, the better I can tell if Disability Advocacy Group is the right fit for you.
What Is the Status of Your Disability Application?
Please attach any recent decisions or records that will help us review your matter.

Cancelof
Do You Have Any Related Cases Pending or Recently Resolved?

Other claim or case (please provide details)
Do you currently owe Social Security any money (an “overpayment”)?
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)

MonthDayYear
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)
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)?
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?
What Medical Conditions Are Keeping You From Working? (select all that apply)

Other
Please Identify Your Medical Providers (select all that apply)
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?
If Yes, What Are Their Ages?
Do You Live With Any Other Household Members?
If Yes, Please Describe (other household members - i.e. spouse, parents)
Is There Anything Else You Would Like Us to Know About Your Case?
Should be Empty:

Request for Case Evaluation

Disability Case Evaluation Questionnaire

Disability Claim Status

Employment and Work History

Medical Status

Family and Living Arrangements