Social Security Appeals intake

Potential clients (injured person) name*
This field is hidden when viewing the form
DOB*
DD slash MM slash YYYY
Inquirer Name (if different)
Inquirer’s relationship to injured person
Mailing Address*
Physical Address (if different)*
City/State/Zip*
Phone
Phone
Email Address*
What is your disability?
Symptoms, body parts, body systems.
What caused your disability?
When do you feel you became disabled?
Was there some event in your life that caused your disability? When? What happened?
Did you work in the 5 - 10 years prior to you becoming disabled?
Have you applied for Social Security before? Was it denied? When?
Date of most recent notice from the SSA?***
Are you currently working?
If not, date last worked?
If so, how many hours do you work per week? How much earn?
Type of work you have done past 15 years? Please be specific.
Name(s) of employers past 15 years. Location(s)
Name / location of health care providers (HCP) who have seen you?
Chronology of your medical care, all the HCPs you have seen, starting with the first one to the most recent.
How have you felt physically since your disability began?
Medications, specific names, dosage, HCP who prescribed, starting when, purpose, side effects?
Has a doctor prescribed a cane or other assistive device for you? Who? When?
Do you have child support obligations? Are you behind?
In which state(s)?
How much owed?
Do you owe student loans?
How much?
Spoken to another lawyer about your Social Security case?

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Social Security Benefits

Social Security Appeals intake

Social Security Appeals intake

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