Intake Form - Pending Claim
First Name (As shown on your Social Security Card)
*
Middle Name (As shown on your Social Security Card)
Last Name (As shown on your Social Security Card)
*
Email
*
Cell phone
*
Alternate phone
Social Security Number
*
Date Of Birth
*
Street address
P.O. Box
City
State
ZiP Code
Age
Sex
Race
Height
Weight
Mother's First and Maiden Name
Father's First and Last Name
City and State of Birth
Citizenship Date (if applicable)
Have you filed an application for Social Security benefits?
YES
NO
When did you file?
Have you already received a denial?
YES
NO
Date of most recent denial
Have you already filed an appeal?
YES
NO
Has an attorney ever represented you in a claim for Social Security benefits?
YES
NO
Do you have a hearing scheduled?
Yes
No
If yes, when is your hearing?
Last Time Worked
Last Employer
Last Job Duties/Requirements
Last Job Length of Employment
Why did the job end?
Describe the type of work that you have had in the last 5 years:
Job 1 – Job Title
Job 1 – Years Worked
Job 1 – Brief Description of Job Duties
Job 2 – Job Title
Job 2 – Years Worked
Job 2 – Brief Description of Job Duties
Job 3 – Job Title
Job 3 – Years Worked
Job 3 – Brief Description of Job Duties
Job 4 – Job Title
Job 4 – Years Worked
Job 4 – Brief Description of Job Duties
How long are you able to sit?
How long are you able to stand?
How much can you lift and/or carry repetitively?
0-5 lbs
5-10 lbs
10-15 lbs
15-20 lbs
25 lbs or more
Do you have any difficulty walking?
YES
NO
How far can you walk?
Physical Impairments - What medical diagnoses keep you from working? (explain why)
Mental Health Impairments - What medical diagnoses keep you from working? (explain why)
Did you complete High School or receive a GED?
YES
NO
What was the highest grade completed?
List your Prescription Medications (and any side-effects you experience from your medicines):
List all Doctors / Clinics / Hospitals / Etc. that you have seen in the last 2 years
1 - Name of Doctor, Hospital or Clinic
1 - Address of Doctor/Hospital/Clinic
1 - Phone Number of Doctor/Hospital/Clinic
1 - Date First Seen
1 - Date Last Seen
1 - Next Appointment Date
2 - Name of Doctor, Hospital or Clinic
2 - Address of Doctor/Hospital/Clinic
2 - Phone Number of Doctor/Hospital/Clinic
2 - Date First Seen
2 - Date Last Seen
2 - Next Appointment Date
3 - Name of Doctor, Hospital or Clinic
3 - Address of Doctor/Hospital/Clinic
3 - Phone Number of Doctor/Hospital/Clinic
3 - Date First Seen
3 - Date Last Seen
3 - Next Appointment Date
4 - Name of Doctor, Hospital or Clinic
4 - Address of Doctor/Hospital/Clinic
4 - Phone Number of Doctor/Hospital/Clinic
4 - Date First Seen
4 - Date Last Seen
4 - Next Appointment Date
5 - Name of Doctor, Hospital or Clinic
5 - Address of Doctor/Hospital/Clinic
5 - Phone Number of Doctor/Hospital/Clinic
5 - Date First Seen
5 - Date Last Seen
5 - Next Appointment Date
Do you use tobacco?
YES
NO
If yes, how much?
Do you drink alcohol?
YES
NO
If yes, how much?
Do you have history of alcohol/drug abuse?
YES
NO
Do you currently use illegal drugs?
YES
NO
Have you ever been to prison / jail?
YES
NO
If yes, what was the reason and how long were you in prison /jail for?
What is your Marital Status?
Single
Married
Separated
Divorced
Widowed
If married, spouse's name:
Please list the names and ages of everyone who lives in your household:
Household Member 1 – Name
Household Member 1 – Relationship
Household Member 1 – Age
Household Member 2 – Name
Household Member 2 – Relationship
Household Member 2 – Age
Household Member 3 – Name
Household Member 3 – Relationship
Household Member 3 – Age
Spousal Income (Monthly)
$
DIB/SSI Income (Monthly)
$
Work Comp Income (Monthly)
$
Retirement Income (Monthly)
$
Food Stamps (Monthly)
$
Unemployment Income (Monthly)
$
Long/Short Term Disability Income (Monthly)
$
Other Income (Monthly)
$
Have you been denied Long Term or Short Term Disability? Explain