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FREE CASE EVALUATION

*First Name:

*Last Name:

*Address:

*City:

*State:

*Zip:

*E-mail address:

*Home Phone:

*Alternate Phone:

Age:

Do you have a SS#?
Yes  No 
(If you answered no to this question, we are unable to assist you with your claim)

How did you hear about our firm?

Search Engine or Website
Newspaper Ad
Television Ad
Friend
Attorney
Medical Professional/Provider
Other

Are you Receiving money from SSA already?:
(If you answered YES to this question, we are unable to assist you with your claim)

Are you currently working and earning $400/month?
Yes  No 
(If you answered YES to this question, we are unable to assist you with your claim)

If not then when was the last month you worked(Month/Year)?

Do you have any of the following disabilities? (select all that apply)

Arthritis or Pain Disorder
Diabetes
Breathing Disorder
Heart Disease
Liver or Kidney Disease
Neurological Disorder
Immune System Disorder
Visual/Hearing/Speech Problem
Cancer
Seizures
Depression/Anxiety
Learning Problems
Other Mental Illness
Other Physical Illness

Briefly explain why you cannot work:

Has a doctor advised you to stop working?
Yes  No 

What kinds of doctors have you seen in the past two years? (select all that apply)

Primary Care
Psychiatrist
Psychologist/Therapist
Neurologist
Orthopedist
Ophthalmologist
Infectious Disease Expert
Endocrinologist
Dermatologist
Rheumatologist
Oncologist
Pediatrician

Are you currently attending school?
Yes  No 

What is the highest grade you completed in school?

Were you in any special education classes?
Yes  No 

Can you read and write in English?
Yes  No 

Do you have cash, assets, or savings worth more than $2000?
Yes  No 

Do you and your spouse have combined income of $600 or more per month?
Yes  No  N/A 

Have you received workers compensation benefits?
Yes  No 

Do you smoke cigarettes?
Yes  No 

Has a doctor ever told you to stop using drugs or alcohol?
Yes  No 

Have you applied for Social Security Disability in the past 2 years?
Yes  No 

Were you denied in the past 60 days?
Yes  No 

If so, did you file an appeal?
Yes  No 

When?
(Month/Year)

Have you had a hearing for your Social Security Disability case?
Yes  No