SOCIAL SECURITY DISABILITY INTAKE SHEET
I. CLIENT INFORMATION
1)
Name:
Name: FIRSTMIDDLE /MAIDENLAST2)HOME ADDRESS
HOME ADDRESSSTREET ADDRESS CITY STATE ZIP
CITY STATE ZIPCan letters and documents be sent to your home?
3)TELEPHONE NUMBERS
TELEPHONE NUMBERSA)Home: AREA CODE-XXX-XXXXCan you be contacted at home?
Can messages be left at home?
Restrictions
B)Cellular: AREA CODE-XXX-XXXX4)Social Security Number
Social Security Number XXX-XX-XXXX5)Date of Birth:
Date of Birth: MM/ DD/ YYYY6)Are you currently receiving Social Security Disability or SSI?
Are you currently receiving Social Security Disability or SSI? 7)Have you received a denial?
Have you received a denial?8)Initial Claim Denial Dated:
Initial Claim Denial Dated: MM/DD/YYYY9)Reconsideration Denial Dated:
Reconsideration Denial Dated:MM/DD/YYYY10)Are you currenly represented in your Social Security claim?
Are you currenly represented in your Social Security claim? 11)When did you last work a full time job?
When did you last work a full time job? MM/DD/YYYY12)Have you attempted to work since then?
Have you attempted to work since then?If your answer was YES, then please state who was your last employer and when did you last attempt to work? 13)Are you now receiving medical or mental health treatment?
Are you now receiving medical or mental health treatment? 14)Who is your doctor?
Who is your doctor?15)Why do you feel you cannot work? What is your disability?
Why do you feel you cannot work? What is your disability?16)Do you have children under 18 years of age when you filed for benefits?
Do you have children under 18 years of age when you filed for benefits?17)If your answer to 16 was YES, then please state the name(s) and birthdate(s):
If your answer to 16 was YES, then please state the name(s) and birthdate(s):18)Are you a High School Graduate?
Are you a High School Graduate? 19)Name of High School and Year of Graduatiion:
Name of High School and Year of Graduatiion: 20)If you did not graduate High School, do you have a GED?
If you did not graduate High School, do you have a GED? 21)What was the highest grade of education you completed?
What was the highest grade of education you completed? 21)If you have a GED, when and where did you get it?
If you have a GED, when and where did you get it? 22)Have you had any further training or college?
Have you had any further training or college? 23)If you have had further training or college, please describe it.
If you have had further training or college, please describe it.24) Please give a history of your past employment:
Please give a history of your past employment:25)Do you or have you ever filed a Workmen's Compensation claim or Personal Injury claim?
Do you or have you ever filed a Workmen's Compensation claim or Personal Injury claim?26)What was the amount of settlement and name of attorney:
What was the amount of settlement and name of attorney: 27)Have you ever drawn unemployment benefits?
Have you ever drawn unemployment benefits? 28)If you have drawn unemployment benefits, please state what dates:
If you have drawn unemployment benefits, please state what dates:29)Do you have a Disability Claim (enough work credits on your work record)?
Do you have a Disability Claim (enough work credits on your work record)?30)Do you have an SSI Claim?
Do you have an SSI Claim? 31)If you have an SSI claim only, what is the household income per month?
If you have an SSI claim only, what is the household income per month?32)Please state the names of all attorneys who have represented you in your Social Security or SSI claim:
Please state the names of all attorneys who have represented you in your Social Security or SSI claim:33)Do you have health insurance coverage or Medicaid benefits?
Do you have health insurance coverage or Medicaid benefits? 34)If no, have you applied for Medicaid benefits?
If no, have you applied for Medicaid benefits? 35)Do you have State or private disability coverage?
Do you have State or private disability coverage? 36)Have you ever been charged with Driving While Impaired, Driving Under the Influence, or any other alcohol or drug-related
Have you ever been charged with Driving While Impaired, Driving Under the Influence, or any other alcohol or drug-related related offense? 37)Do you now have, or have you ever had, any problems with drug or alcohol abuse?
Do you now have, or have you ever had, any problems with drug or alcohol abuse?38)Have you ever abused prescription medications?
Have you ever abused prescription medications?39)What else do you think our attorneys should know about your claim?
What else do you think our attorneys should know about your claim?By clicking the SUBMIT BUTTON below, you will transmit the information in this Intake form to the Dawson Law Firm, pllc. The information is only provided to familiarize the Firm with your situation to assist us in any discussions we may have with you regarding your issues and concerns. Nothing herein creates an attorney client relationship, although the contents shall remain confidential unless otherwise requested by the Visitor.
