Colorado Springs

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800-975-8367
Social Security Case Evaluation
SiteLockWe can evaluate your case if:
Things to know before you fill out the form:
  • If you've had a Social Security hearing and are appealing the Judge's decision fill out this form instead.
  • 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?*
If you're older than age 50, have you done a desk-job in the past 15 years? Yes No
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 a 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?* What does this mean? Yes No
Have you applied for or received unemployment benefits since you stopped working?* Yes No
Your Application for Benefits
Date you became unable to work (mm/yyyy)* (mm/yyyy)
Have you filed a claim with SSA?* Get help with filing a claim. Yes No
Date you filed the claim :  (mm/yyyy)
Type of benefits you applied for (check all that apply):Click to see info about the types of benefits. SSDI (Social Security Disability Insurance)
SSI (Supplemental Security Income)
Children's SSI  -  PLEASE FILL OUT THIS FORM INSTEAD
Disabled Widow(er)'s Benefits
Retirement Benefits
Other
**For appeals to the Appeals Council and Federal Court, please fill out our Social Security Appeals Form.
Have you received a denial letter from SSA?* Click to see an example of a denial letter. Yes No
Date of denial letter (mm/dd/yyyy): 

If you've been denied, why did SSA deny you? (please check all that apply)
 SSA said I can do other work
SSA said I do not meet their rules for disability
SSA said that I do not meet their rules for disability as of :  (mm/dd/yyyy)
SSA said that my income (or my spouse's) is too high
SSA said that my condition would improve within 12 months
Other:

If you have been denied, have you filed a Request for Hearing form? Click to see 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, do you have a hearing date?
Yes No
Date of hearing: (mm/dd/yyyy)
Judge assigned to your case:

About Your Disability
Please list your disabling conditions:*
Why do you feel that you can't work at any job?
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? Click to see why we need to know this. 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: 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.