Social Security Appeal Case Evaluation

Colorado Springs

Toll-Free

719-632-4808
800-975-8367

Social Security Appeals Case Evaluation
APPEALS ONLY: Appeals Council & Federal Court

We can evaluate your appeal case ONLY if:

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

Title:*
First name:*
Last name:*
Address:
City:*
State:*	Don't live in Colorado? Call 800-431-2804 to find an attorney near you.
Zip:
Daytime phone:*
Mobile phone:
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 are you?*
Date you last worked (mm/yyyy):*	(mm/yyyy)
Why did you stop working?	Quit or was fired because of my disability. Was laid off. Other, non-disability related reason. I'm still working. If you're still working: How many hours per week are you working? Where are you working? What type of work are you doing?
Did you work 5 out of the last 10 years before becoming disabled?*	Yes No
Have you applied for or received unemployment benefits since you stopped working?*	Yes No

Your Appeal

About Your Disability

Please list your disabling conditions:*
Have any of your doctors told you not to work, or given you work restrictions?	Yes No If yes, please fill in the doctor's name and any restrictions given:
Please list the medications you take for your disabling conditions:
Please list all doctors who have treated you for your disabling conditions:
How often do you see a doctor?
Please list any surgeries you have had related to your disabilities:
Please list all the doctors SSA has sent you to see:
Have you ever abused drugs or alcohol?	Yes No If yes, have you ever received drug treatment? Yes No Are you still using? Yes No

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:
Please enter the security code you see above:
	It may take a few minutes for the form data to go through. Please do not hit the button more than once.

Date you became unable to work (mm/yyyy):*	(mm/yyyy)
Type of benefits you applied for (check all that apply):	SSDI (Social Security Disability Insurance) SSI (Supplemental Security Income) Children's SSI Disabled Widow(er)'s Benefits Other
Date of your hearing (mm/dd/yyyy):	(mm/dd/yyyy)
Date of your unfavorable decision:*
Name of the judge who denied you:
Have you filed an appeal with the Appeals Council?	Yes No
Have you received a decision from the Appeals Council?	Yes No If yes, what is the date of the decision: (mm/dd/yyyy)
Have you filed an appeal with the Federal District Court of CO?	Yes No
Have you received a decision from the Federal District Court?	Yes No
Did a representative help you at any point in your case? (check all that apply)	An attorney helped me with my hearing A non-attorney representative helped me with my hearing I went to the hearing on my own An attorney helped me with my appeal A non-attorney representative helped me with my appeal I appealed on my own If someone helped you with your case, please enter their name: If someone helped you with your case, why are they not helping you with your appeal?