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Social Security Case Evaluation-Children's SSI

We can evaluate your case if:

You need help with a Children's SSI claim - if not, click here.
You have received a denial from Social Security.

Things to know before you fill out the form:

It will take approximately 10 minutes to complete this form.
No attorney-client relationship is established by submitting this form.
All information you submit to us will be kept confidential.
Fields in red are required.

Child's First Name

Child's Last Name


Your Name

Your relationship to child

Street Address

Apt.#

City

State

Zip

You will need to enter either a phone number or e-mail address so that we can contact you.

Your Phone number

Your E-mail

Best time of day to reach you

How did you get to us (check all that apply)
Search engine
FindLaw.com
Qwest Yellow Pages
Dexknows.com (Dex Online)
Facebook
LinkedIn
Spencer & Spencer Newsletter
Friend
Client of ours
Link from another site
Other
How old is the child?
Date the child became disabled (give an approximate date if you are unsure)


Has the child ever worked?
If so, date child last worked

Why did the child stop working?
Quit or was fired because of disability.
Was laid off.
Other, non-disability related reason.
Child is still working:
How many hours per week is the child working?
Where is the child working?
What type of work is the child doing?

Type of Social Security case (check all that apply)
Children's SSI
Survivor Benefits
Other
**For appeals to the Appeals Council and Federal Court, please fill out our Social Security Appeals Form.
Have you filed a claim with SSA?: yes no; Date you filed claim
Have you received a denial from SSA yet? (Requires Acrobat Reader to view): yes no; Date of the denial letter

If you have received a denial, what is the reason SSA gave for denying the claim?

If you have been denied, have you filed a Request for Hearing? (Requires Acrobat Reader to view): yes no; Date Request was filed
If yes, do you have a Hearing date?: yes no; Date of hearing; Judge assigned to case

Please list the child's disability(s) in these 5 areas. If none, type "none"

1. Cognitive/Communicative: ability to learn, understand, solve problems:

2. Motor Skills: the ability to move about, or use their hands for tasks:

3. Social Skills: the ability to form and maintain relationships, or get along with others:

4. Personal: take care of personal needs such as dressing, grooming and feeding themselves:

5. Concentration, Persistence or Pace: ability to sustain attention and concentration on an activity or task:

Is the child in special education classes, or does the child have special accommodations at school?
yes no
If yes, please describe:

Please list all medications the child currently takes

Has the child ever abused drugs or alcohol?
yes no
If so, has the child received drug treatment?

Is the child still using?

Please list all doctors the child seen regarding their disability(s)

How often does the child see a doctor?

Please list any surgeries the child has had related to your disability(s)

Please list all doctors SSA sent the child to see

Why did you decide to contact an attorney?

Please give us any additional information about the case that you feel will help us evaluate the case

ecurity Question:

What letter has the gavel behind it?

Hit "Submit" and we will review your case. Someone from our office will contact you.

After you have filled out the form, a lawyer will review your case, and someone from our office will contact you.

You can send this information over the Internet by clicking submit at the bottom of the form. If you are concerned about the privacy of this information, you can fill the form, print it and fax it to us at: (719) 632-4807.