Social Security Case Evaluation

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

Best time of day to reach you

Please choose one morning afternoon evening

 

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

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

Qwest Yellow Pages

Dex Online

Spencer & Spencer Newsletter

Friend

Client of ours 

Link from another site

Other   

 

How old are you?           

 

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 1989 before 1988

 

Date you last worked

  Select month Never Worked Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec.            Select year Never Worked 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

 

Why did you stop working?

Quit or was fired because of my disability.

Was laid off.

Other, non-disability related reason.

I am still working:    

        How many hours per week are you working?

        Where are you working?

        What type of work are you doing?

 

Have you worked 5 out of the last 10 years?

 yes  no

 

What type of work did you do? (waitress, teacher, etc.)

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

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 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

Disability Information

Please list your disability(s)

 

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 all medications you currently take

Have you ever abused drugs or alcohol?

yes   no

 

If so, have you ever received drug treatment?

Please Select One Not Applicable No Yes

 

Are you still using?

Please Select One Not Applicable No Yes

 

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

 

How often do you see a doctor?

 

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

 

Please list all doctors the Social Security Administration

has sent you to see

 

Why did you decide to contact an attorney?

 

Please give us any additional information about your Social Security case

that you feel will help us evaluate your case