Social Security Disability Intake Form
Have you already spoken to someone in our office?
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Yes
No
How did you hear about us?
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WCB Number for this Case
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Full Name
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Social Security Number
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Street Address
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City
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ZIP
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Home Phone
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Cell Phone
Fax
Email Address
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How would you prefer to be contacted?
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Email
Phone
Mail
Gender
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Male
Female
Prefer not to say
Date of Birth
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-
Month
-
Day
Year
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Place of Birth
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Relationship Status
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Married
Single
Divorced
Widowed
Do you have any children under the age of 18?
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Yes
No
Do you speak English?
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Yes
No
Can you read English?
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Yes
No
Can you write in English?
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Yes
No
Maybe
Highest degree of education?
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None
Elementary School
High School
Associates
Bachelors
Masters
PHD
Other
Military Service Prior to 1968
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Yes
No
Date Last Worked
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Month
-
Day
Year
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Were you self-employed?
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Yes
No
What types of activities do you normally perform at work?
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Your Injury or Illness
Please list all illnesses, injuries, conditions that limit your ability to work
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Were your illnesses, injuries, or conditions related to work?
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Yes
No
Have you filed or intend to file for workers' compensation benefits?
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Yes
No
Return to Work
Have you returned to work?
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Yes
No
Medical Treatment for this Injury
What was the date of your first treatment?
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Month
-
Day
Year
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Where did you first receive treatment?
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Name, Address, Phone & Fax of the Doctor(s) Treating you for this Injury, condition, or Illness
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Have you had any testing done? Please list all that apply.
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Additional Information
Is another attorney presently working on this claim?
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Yes
No
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