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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Email *
Full Name *
First and last name
Phone Number *
Current Age? *
Are you a U.S. citizen? *
What is the highest level of education you have received? *
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? *
Required
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? *
Required
How were you referred to our office? *
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