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Security Disability Evaluation

The purpose of this form is so you can tell us your story, and get the ball rolling as soon as possible. Sometimes, we find the best thing to do when beginning a legal matter is to get everything 'down on paper'. We hope this form will help you feel better, by knowing your situation will be reviewed by an attorney right away. 
 

Please know that all information is kept secure and confidential, but this form does not does not constitute or create an attorney-client relationship. If you would like further details, please review our disclaimer.

First & Last Name:
 
City:
 
State:
 
Zip Code:
 
Phone Number:
 
E-mail Address:
 
Age:
 
Education (last grade completed):
 
Work History:
 
Date Last Worked:
 
Briefly describe problems that affect your ability to work:
 
Have you filed a claim for social security disability/SSI:
Yes
No
 
If yes, was your claim denied:
Yes
No
 
If yes, what is the date of denial:
 
Is there anything else we should know about your situation, right now?: