Best Day/Time to Reach You*
Is the Applicant between ages 17 1/2- 65 years old? *
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? *
Is the applicant a United States citizen or a documented, permanent resident? *
Does the applicant have an active application with Social Security or is currently in a Social Security Disability Benefits Appeal process? *
Is the applicant currently working with an attorney, or other professional, on an SSI/SSDI application? *
Does the applicant earn less than $1,350 (or $2,260 with vision disability) per month? *
Highest Grade Completed in School*
Has the Applicant been turned down for SSI/SSDI? *
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)?*
Medical/Mental Health Services Screening
Please tell us about your health challenges. Please list the different health challenges separately. Health Challenge 1:*
Please tell us about where you receive health services for each health challenge. Treatment Provider 1: *
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?
Please list and describe your health symptoms and when they began? *
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
Does the applicant have any other income or assets? If yes, please explain*
Does the applicant have a history of alcohol or drug abuse?
If yes, please list the substances.
Is the applicant currently using any non-prescribed drugs or alcohol? *
If Yes, what substances are being used and how often
Treatment History Form: Treatment Facility 1*
Treatment History Form: Treatment Facility 2
Treatment History Form: Treatment Facility 3
Treatment History Form: Treatment Facility 4
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.
