Case Evaluation Form
Thank you for taking the time to complete this case evaulation form. Please answer every question to the best of your ability. If a question doesn't apply to you, please respond "N/A." If you don't know the answer to a question or do not have the information, please respond "I don't know" or "I don't have that information." Once you have completed and submitted this form, our office will contact you to discuss your case further. Please note that the completion of this form does not establish an attorney-client relationship in any way.
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First and last name
Are you a U.S. citizen?
What is the highest level of education you have received?
less than high school
high school degree or GED
college degree or more
Are you currently working either part-time or full-time?
What serious medical impairments prevent you from working a full-time job, i.e., why are you disabled?
Do you use any of the following assistive devices?
Shower and/or toilet bars
House ramp for easier entry
Handicap parking permit
Brace of any kind (for example, knee, back, ankle, etc.)
None of the above
Have you applied for Social Security disability benefits?
Have you been denied Social Security disability benefits?
What stage is your Social Security disability claim at?
Initial application denied
Request for reconsideration
Request for reconsideration denied
Request for hearing
I received an unfavorable decision or partially favorable decision from the judge
How were you referred to our office?
National Organization of Social Security Claim Representatives
National Association of Disability Representatives
Referral from a friend or family member
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This form was created inside of Jason A. Jenkins, P.A..