FREE Social Security Disability Questionnaire

Feel free to enter as much or as little information as you choose. What you send will give our team a preview of your case before an actual intake (also free, please call), and determine what will be most important to talk about in our interview.

Any information you share with the firm is between us. We will keep your information just as confidential as we would for an established client.

Note: You don't have to complete this form to talk to us. Also, filling this out or just calling us does not make us your attorney. Only a contract does that.

Name *
Phone Number
Phone Number
Please describe, in your own words, how you are disabled.
Have you applied for Social Security Benefits Already? *
If you've applied for disability, have you been denied yet?
If you've been denied, do you know why?
Which of the following best describes your most serious disability? *
When would you say you reached your current level of disability?
Are you currently seeing your doctor on a regular basis
What is your educational history? *
Have you stopped working?
Which of the following best describes your work history? *
How many years of work do you have?
Do you have any other pending claims or sources of payment for medical expenses?
Do you smoke, use alcohol or any other non-proscribed medicines of any sort to cope with your disability?
This is very common among applicants and will not necessarily hurt a case. This will only affect how we advise you.
If you have anything else you'd like us to know about your case before we call, please fill us in below.