Social Security Case Evaluation

General Information

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

 

Phone

 

E-mail

 

Best time of day to reach you

Please select one morning afternoon evening

 

How did you get to us (check all that apply)

Search engine  Please select one Alta Vista AOL Search Google Goto HotBot Looksmart Lycos MSN Netscape Northern Light WebCrawler Yahoo Other

Qwest Yellow pages

Dex Online

Friend

Client of ours 

Link from another site

Other   

How old are you?  

Claim Information

Type of social security case (check all that apply)

SSDI (Social Security Disability Insurance)

SSI (Supplemental Security Income)

Children's SSI - Your relationship to the child

Disabled Widow(er)'s Benefits

Retirement Benefits

 

Have you had a hearing in front of a judge?

    yes  no-if you've selected "no," click here>>

Date of your hearing

Date of your Unfavorable Decision (Requires Acrobat Reader to view)

 

Have you filed an appeal with the Appeals Council? (Requires Acrobat Reader to view)

    yes  no

 

Have you received a decision from the Appeals Council? (Requires Acrobat Reader to view)

    yes  no

   Date of the Appeals Council Decision

 

Have you filed an appeal with the Federal District Court for the District of CO?

    yes  no

 

Have you received a decision from the Federal District Court?

    yes  no

   Date of the Federal District Court Decision

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 pursued the hearing on my own

An attorney helped me with my appeal

A non-attorney representative helped me with my appeal

I pursued the appeal on my own

 

If someone helped you with your case, why is he or she not helping you with your appeal now?

Disability Information

Date you became disabled (give an approximate date if you are unsure)

  Select month Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec.                         Select year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 before 1990

 

Date you last worked

  Select month Never worked Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec.                       Select year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 before 1988 Never worked

 

    I am still working      

        How many hours per week are you working?

        Where are you working?

        What type of work are you doing?

 

Have any of your doctors told you not to work, or given you restrictions?

yes   no

 

If yes, please fill in the doctor's name and any restrictions given:

 

Please list your disability(s)

 

 

Please list the Medications you currently take

Have you ever abused prescription or other drugs?

yes   no

 

If so, have you ever received drug treatment?

Not Applicable No Yes

 

Are you still using?

Not Applicable No Yes

 

Please list all doctors you have seen on your own about your disability(s)

 

Please list any surgeries you have had related to your disability(s)

 

Please list all doctors SSA has sent you to see

 

Why did you decide to contact an attorney?

 

Please give us any additional information that you feel

will help us evaluate your case