Social Security Justice Intake Questionnaire
Type of Case
Full Name
Your answer
Address
Your answer
Telephone Number
Your answer
Social Security #
Your answer
Date Of Birth
Your answer
List of Disabilities
Your answer
Type of Disability
Referral Source
Your answer
Status of Disability Claim
Highest Grade Completed
Your answer
Were you in special education as a child
Marital Status
Your answer
Tobacco Use, Drug Use, Alcohol Abuse
Your answer
Type of Insurance
Your answer
DO you currently have an attorney
Date you last worked
MM
/
DD
/
YYYY
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