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Social Security Case Evaluation
CHILDREN'S SSI
SiteLock We can evaluate your child's case if:
  • You need help with a Children's SSI claim. If not, click here.
  • The child has applied for Social Security benefits. If they haven't applied, please download our Application Kit.
  • The child has received a denial from Social Security.
Things to know before you fill out the form:
  • It will take about 10-15 minutes to complete this form, and the information you send us is confidential.
  • No attorney-client relationship is established by submitting this form.
*Required fields.
Contact Information
Child's first name:*
Child's last name:*
Child's gender:* Male Female
Your first name:*
Your last name: *
Your relationship to child:*
Address:
City:*
State:*   Don't live in Colorado? Call 800-431-2804 to find an attorney near you.
Zip:
Your daytime phone:*
Mobile phone:
Your e-mail address:*
Referral Source
How did you find us? Please check all that apply:
Saw ad in the phone book
Search engine
Findlaw.com
Dexknows.com (Dex Online)
Facebook
LinkedIn
Client of ours
Other
General Information
How old is the child?*
Has the child ever worked? Yes No

If yes, date child last worked:   (mm/yyyy)

If yes, why did the child stop working?
Quit or was fired because of the disability.
Was laid off.
Other, non-disability related reason.
Child is still working.

If the child is still working:
How many hours per week are they working?
Where are they working?
What type of work are they doing?
Is the child in special education classes, or does the child have special accommodations at school? Yes No
The Child's Application for Benefits
Date the child became disabled (mm/yyyy)*   (mm/yyyy)
Has the child filed a claim with SSA? Yes No
Date claim filed: (mm/yyyy)
Type of benefits child applied for (check all that apply): Children's SSI
Survivor's Benefits
Other
**For appeals to the Appeals Council and Federal Court, please fill out our Social Security Appeals Form.
Has the child received a denial letter from SSA?* Yes No
Date of denial letter: 

If the child was denied, why did SSA deny them? (please check all that apply):
SSA said the child does not meet their rules for disability
SSA said that the child's family earns too much to qualify
SSA said that the child's condition would improve within 12 months
Other:

If the child received a denial, have you filed a Request for Hearing form?
Yes No

If you filed a Request for Hearing form:
Date Request for Hearing filed: (mm/dd/yyyy)

If you filed a Request for Hearing form, does the child have a hearing date?
Yes No
Date of hearing: (mm/dd/yyyy)
Judge assigned to the child's case:
About The Child's Disability
Please list the child's disabling conditions:*
Please list the medications the child takes for their disabling conditions:
Please list all doctors who have treated the child for their disabling conditions:
Please list any therapists the child sees, including physical, psychological, speech, or occupational:
How often does the child see a doctor?
Please list any surgeries the child has had related to their disabilities:
Please list all the doctors SSA sent the child to see:
Has the child ever abused drugs or alcohol? Yes No

If yes, have they received drug treatment?
Yes No

The Child's Functional Abilities

Please list the child's disability(s) in these 6 areas. If none, type "none."
1. The ability to learn, understand, or solve problems:*
 
2. The ability to move around, or use their hands for tasks:*
 
3. The ability to form and keep relationships, or get along with others:*
 
4. The ability to take care of personal needs such as dressing, grooming and feeding themselves:*
 
5. The ability to pay attention or concentrate on an activity or task:*
 
6. The overall health and well-being of the child:*

 
Additional Information
Why did you decide to contact an attorney?
Please give us any additional information that you feel will help us better evaluate your case:
Security Question
Security Code: Security Code
Please enter the security code you see above:
It may take a few minutes for the form to go through.
Please do not hit the button more than once.