Intake Form - New 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
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
We will now ask you some information about your most recent job:
Most recent job title
Type of Business
Most recent job – Hours per Day
Most recent job – Days per Week
Choose rate of pay per hour, day, week, month or year below (choose 1):
Rate of Pay (per Hour)
$
Rate of Pay (per Day)
$
Rate of Pay (per Week)
$
Rate of Pay (per Month)
$
Rate of Pay (per Year)
$
The questions below are still about your most recent job:
Describe in detail the tasks you did in a typical workday. Examples of tasks include stocking shelves, greeting customers, scheduling appointments, or maintaining records.
If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote or completed and how much time you spent on it per workday or workweek.
If any of the tasks listed above involved supervising others, describe who or what you supervised and what supervisory duties you had. Examples of supervisory duties include evaluating employee job performance, making schedules, or maintaining time records.
List the machines, tools, and equipment you used regularly when doing this job, and explain what you used them for. Examples of equipment include computer, telephone, forklift, air compressor, or meat slicer.
Did this job require you to interact with coworkers, the general public, or anyone else?
Yes
No
If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or workweek. Examples include answering customer questions on the phone for 5 hours per day or showing clients properties for sale in person for 4 hours per day.
The questions below are still about your most recent job:
How much of your workday were you standing and walking (combined), in hours/minutes?
How much of your workday were you sitting, in hours/minutes?
How much of your workday were you stooping (bending down and forward at the waist), in hours/minutes?
How much of your workday were you kneeling (bending your legs to rest on your knees), in hours/minutes?
How much of your workday were you crouching (bending your legs and back down and forward), in hours/minutes?
How much of your workday were you crawling (moving on your hands and knees), in hours/minutes?
How much of your workday were you using your fingers to touch, pick, or pinch objects, in hours/minutes?
Did you use one arm or both arms for the above action?
One Arm
Both Arms
How much of your workday were you using your hands to seize, hold, grasp, or turn objects, in hours/minutes?
Did you use one arm or both arms for the above action?
One Arm
Both Arms
How much of your workday were you reaching at or below your shoulder level, in hours/minutes?
Did you use one arm or both arms for the above action?
One Arm
Both Arms
How much of your workday were you reaching overhead (above your shoulder), in hours/minutes?
Did you use one arm or both arms for the above action?
One Arm
Both Arms
How much of your workday were you climbing stairs or ramps, in hours/minutes?
How much of your workday were you climbing ladders, ropes, or scaffolds, in hours/minutes?
Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you did this during a typical workday.
What was the heaviest weight you lifted at this job?
Less than 1 lb.
Less than 10 lbs.
10 lbs.
20 lbs.
50 lbs.
100 lbs. or more
Other
Select the weight FREQUENTLY lifted (i.e., 1/3 to 2/3 of the workday):
Less than 1 lb.
Less than 10 lbs.
10 lbs.
25 lbs.
50 lbs. or more
Other
Did this job expose you to any of the following? Check all that apply.
Outdoors
Extreme heat (non-weather related)
Extreme cold (non-weather related)
Wetness
Humidity
Hazardous substances
Moving mechanical parts
High, exposed places
Heavy vibrations
Loud noises
Other
If other, what did the job expose you to?
If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed:
Explain how your medical conditions would affect your ability to do this job:
We will now gather information to file a new Social Security Disability Benefits claim:
What was your last year in school?
Are you currently married?
YES
NO
Spouses Date of Birth
Spouses SSN
Date of Marriage
City and State of Marriage
Any Prior Marriages?
YES
NO
If yes, any that last at least 10 years or more?
YES
NO
Only fill in if divorced:
If divorced - spouse's name
If divorced - spouses Date of Birth
If divorced - Spouses SSN
If divorced - Date of marriage
If divorced - City and state of marriage
If divorced - Date of Divorce
If divorced – City and State of Divorce
Is your Ex-Spouse Still Living
YES
NO
Any children under the age of 18?
YES
NO
If yes, SSN for each child:
Any children disabled prior to age 22?
YES
NO
If yes, SSN for each child:
Any children 18 or 19 years old and still in high school?
YES
NO
Wages/earnings last year
$
Wages/earnings 2 years ago
$
Wages/earnings 3 years ago
$
Currently Working?
YES
NO
If yes, how many hours working per week?
Current Hourly Wage?
$