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Social Security Case Evaluation-Short Form

We can evaluate your case if:

You are applying for Social Security benefits.
You have received a denial from Social Security.

Things to know before you fill out the form:

If you have had a Social Security hearing and are appealing the Judge's decision click here.
It will take approximately 5 minutes to complete this form.
No attorney-client relationship is established by submitting this form.
All information you submit to us will be kept confidential.
Fields in red are required.

Title


First Name

Last Name

Street Address

Apt.#

City

State

Zip

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

Phone number

E-mail

Best time of day to reach you

How did you get to us (check all that apply)
Search engine
FindLaw.com
Qwest Yellow Pages
Dexknows.com (Dex Online)
Facebook
LinkedIn
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)


Date you last 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?
I have mostly done sedentary work (remained seated most of the day, e.g., secretary)
I have mostly done light work (on your feet most of the day, e.g., cashier)
I have mostly done medium-heavy work (on your feet most of the day & lifted heavy objects, e.g., construction work)
Have you applied for or received unemployment benefits since you became disabled?
yes no
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, 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 have enough quarters
          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? (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
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 check all that apply:
My primary doctor told me not to work
A doctor I no longer see told me not to work
My psychologist or therapist told me not to work
A non-doctor (nurse or physician's assistant) told me not to work
A doctor I saw once or for a disability evaluation told me not to work
Please list all prescribed medications you currently take
(check all that apply)
medications for pain
psychiatric medications
medications for another disabling condition
How often do you see the doctor?

Have you ever abused drugs or alcohol?
yes no
If so, have you ever received drug treatment?

Are you still using?

Please give us any additional information
that you feel will help us evaluate your case

Security Question:

What letter has the gavel behind it?

Hit "Submit" and we will review your case. Someone from our office will contact you.