Apply for Benefits Assistance

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Apply for Disability Benefits Assistance

We are able to assist when applying for benefits, such as SSI/SSDI, if you are struggling with paperwork, finding necessary information or tracking down records. Fill out the form on this page to be referred to one of our disability benefits team.

There is currently a waitlist for disability benefits assistance; a staff member will contact you within ten (10) business days after receiving this completed form.

Request for Help with a Disability Claim

Date *

Name of Person Requesting Services *

Phone

Best Day/Time To Reach You

Referral Source

Applicant Date of Birth *

Address *

Please share best ways to contact applicant, including phone, email or backup person who can reach applicant with important information. *

Is the Applicant between ages 17 1/2 - 65 years old? *

Yes

Is the Applicant a resident of: *

Does the Applicant have a medical condition (physical, mental or combination of both) that is expected to last 12 months or result in death and interferes with working? *

Yes

Is the Applicant a United States citizen or a documented, permanent resident? *

Yes

Does the Applicant have an active application with Social Security or currently in the Social Security Disability Benefits appeal process? *

Yes

Is the Applicant currently working with an attorney, or other professional, on an SSI/SSDI application? *

Yes

Does the Applicant earn less than $1,350 (or $2,260 with vision disability) per month? *

Yes

Highest Grade Completed in School *

Has the Applicant been turned down for SSI/SSDI? *

Yes

If Yes to last question, what is the date last denied?

Has the Applicant been turned down for Aid to the Needy and Disabled (AND)? *

Yes

Medical/Mental Health Services Screening

Please tell us about health challenges. Please list the different health challenges separately. Health Challenge 1: *

Health Challenge 2:

Health Challenge 3:

Health Challenge 4

Tell us about where you receive health services for each health challenge. Treatment provider 1: *

Treatment 2:

Treatment 3:

Treatment 4:

Additional Screening Questions related to SSI/SSDI Eligibility

Please describe if your medical condition is expected to last for 12 months and if it is expected to stay the same; get better; or get worse. *

Please identify your medical conditions(s) that prevent you from working. Be detailed and specific. *

Please tell us the last time you worked, where you worked and the date of the last day worked. *

Please tell us the reason(s) that you stopped working. *

Please tell us what is currently making it difficult for you to work and keep a job. *

Have you worked in the last 10 years? *

Yes

Please list and describe your health symptoms and when they began? *

Symptoms create the limitations which are preventing your ability to work and earn $1,550 per month or $2,590 with a vision disability.

Please list all the jobs you have worked in the last 15 years. List the type of business where you worked, your job title, hours worked per week and the start and end dates when you were employed.

Does the Applicant have any other income or assets? *

Yes

If Yes, please explain:

Does the Applicant have a history of alcohol or drug abuse? *

Yes

If Yes please list the substances:

Is the Applicant currently using any non-prescribed drugs or alcohol? *

Yes

If Yes what substances are being used and how often

Treatment History Form: Treatment Facility 1 *

Reason(s) for Treatment *

Date Treatment Started *

Date Treatment Ended *

Treatment Facility 2

Reason(s) for Treatment

Date Treatment Started

Date Treatment Ended

Treatment Facility 3

Reason(s) for Treatment

Date Treatment Started

Date Treatment Ended

Treatment Facility 4

Reason(s) for Treatment

Date Treatment Started

Date Treatment Ended

Please list all additional connections and treatment providers for medical and mental health services:

Medication Form and Information Please list all medications you take, the dose required, the purpose and the side effect for each medication. *

Please start gathering all medical records that support the claim for disability. The medical records will be needed in order to fill out the forms to process your claim.

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