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Center for Independence

Empowering People with Disabilities since 1982

CFIGJ

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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 members.

First name*

Last name*

Email*

Phone 1*

Alternate Phone

Best Day/Time to Reach You*

Referral Source*

Birthday*

Month

Day

Year

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

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

Yes

No

Which County does the applicant reside in? *

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

No

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

Yes

No

Does the applicant have an active application with Social Security or is currently in a Social Security Disability Benefits Appeal process? *

Yes

No

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

Yes

No

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

Yes

No

Highest Grade Completed in School*

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

Yes

No

If yes to the last question, what is the date last denied? *

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

Yes

No

Medical/Mental Health Services Screening

The Social Security Administration (SSA) defines disability as having a physical or mental condition, or combination, that prevents an individual (or is expected to prevent) the individual from earning $1,550 per month (2024), or $2,590 per month for someone with a vision disability, for at least 12 months. There must be evidence of the individual's medical or mental health diagnosis and how the condition prevents them from working.

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

Health Challenge 2:

Health Challenge 3:

Health Challenge 4:

Please tell us about where you receive health services for each health challenge. Treatment Provider 1: *

Treatment Provider 2:

Treatment Provider 3:

Treatment Provider 4:

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 condition(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 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

No

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. *

Please select all services applicant is currently receiving

SSI

SSDI

Medicare

Medicaid

VA Benefits

AND

SNAP

OAP

TANF

Does the applicant have any other income or assets? If yes, please explain*

Does the applicant have a history of alcohol or drug abuse?

Yes

No

If yes, please list the substances.

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

Yes

No

If Yes, what substances are being used and how often

Treatment History Form: Treatment Facility 1*

Reasons for treatment*

Date Treatment Started*

Month

Day

Year

Date Treatment Ended*

Month

Day

Year

Treatment History Form: Treatment Facility 2

Reasons for treatment

Date Treatment Started

Month

Day

Year

Date Treatment Ended

Month

Day

Year

Treatment History Form: Treatment Facility 3

Reasons for treatment

Date Treatment Started

Month

Day

Year

Date Treatment Ended

Month

Day

Year

Treatment History Form: Treatment Facility 4

Reasons for treatment

Date Treatment Started

Month

Day

Year

Date Treatment Ended

Month

Day

Year

Medication Information: Please list all medications you take, the dose required, the purpose and the side effects for each. *

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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Click Here for Assessment

Community Partners

Grand Junction Office

Service Area: Mesa & Delta Counties

Address: 740 Gunnison Ave.

Grand Junction, CO 81501

Phone: 970-241-0315

Toll Free: 800-613-2271

FAX: 970-245-3341

Hours: 8a-5p M-Th, 8a-12p F

Closed Daily 12:00-12:30 for lunch

Glenwood Springs Office

Service Area: Eagle, Pitkin & Garfield Counties

Address: 401 27th St, Ste 115

Glenwood Springs, CO, 81601

Phone: 970-718-5155

Toll Free: 800-613-2271

FAX: 970-245-3341

Hours: 8a-5p M-Th

Closed Daily 12:00-12:30 for lunch

Montrose Office

Service Area: Montrose, Ouray
& San Miguel Counties

Address: By Appointment

Phone: 970-765-2016

Toll Free: 800-613-2271

Fax: 970-765-2018

Hours: By appointment only

Salida Office

Service Area: Chaffee, Lake, Gunnison
& Hinsdale Counties

Address: By Appointment

Phone: 970-765-2016

Toll Free: 800-613-2271

Fax: 970-765-2018

Hours: By appointment only

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