Intake Questionnaire

for claimant seeking benefits from the Social Security Administration (SSA)

How did you hear about us?

Phone book:

DEXVerizonYellow Book

Online:

DEX Knows.comSuperPages.comYellowBook.comLawyers.comOur WebsiteOther (List below)





If you are helping someone else and are not the claimant / potential client



Financial Information

Have you collected any unemployment benefits since you last worked?

YesNo

Do you have any disability or retirement income?

YesNo

Do you receive any child support?

YesNo

Do you receive any spousal maintenance a/k/a alimony?

YesNo

Are you receiving cash assistance from your township or the state?

YesNo

Do you have any other income currently?

YesNo

Does your spouse work full time?

YesNo

Other than the house you live in, and the car you drive, do you own assets worth more than $2000?

YesNo

Workers' Compensation Information

Have you ever filed a workers' compensation claim?

YesNo

If so, for each claim, please provide information below:

#1. Approx date of injury

Is the case over now?

YesNo

If so, did you receive a lump sum of money at the end of the case?

YesNo


If the case is still pending, have you received any periodic payments (known as Temporary Total Disability or TTD payments)?

YesNo


Are you still receiving those payments?

YesNo

Who is/was your attorney?



#2. Approx date of injury

Is the case over now?

YesNo

If so, did you receive a lump sum of money at the end of the case?

YesNo


If the case is still pending, have you received any periodic payments (known as Temporary Total Disability or TTD payments)?

YesNo


Are you still receiving those payments?

YesNo

Who is/was your attorney?



Drug & Alcohol Information

Since you stopping working full time, have you used any illegal substances or abused any substances?

YesNo


Have you had any treatment for this?

YesNo

When is the last time you used?

Health Insurance Information

Do you currently have health insurance?

YesNo

If so, what type?

Private Plan

Medicaid (medical card)

VA

Health Care Information

Have you been getting regular health care treatment since you stopped working full time?

YesNo

When is the last time you saw a doctor?

Attorney Information





ID Information for claimant / potential client




Date of Birth


Contact Information











Status of Claim at Social Security Administration

Status of Claim at Social Security Administration


Please look at your application summaries or denials

Retirement, Survivors, and Disability Insurance

Supplemental Security Income


Your SS#Spouse's SS#Parent's SS#Adult Child's SS#

Prior Claim Information

Have you ever applied before the claim described above?

YesNo

Were you awarded benefits?

YesNo

If not, approx. when was that prior claim first denied?

Family Information

Marital Status

SingleDivorcedMarriedWidowedWidowered


Are any of your children disabled?

YesNo

Are either of your parents disabled, retired or deceased?

YesNo

Education Information

How far did you go in school?

Grades:

K123456789101112

College or trade school:

1 yr

2 yrs

3 yrs

4 yrs

5+ yrs

Do you have any certificates or degrees?

Associates in:

BA / BS in:

Certificates/Other:

Last Work Activity

Are you working currently?

YesNo



If not, when did you stop working?


Did you decrease your hours before stopping work altogether?

YesNo

If so, when?

Work History - for past 15 years

Approx dates

To


On feet more than 2 hrs/day?

YesNo


Approx dates

To


On feet more than 2 hrs/day?

YesNo


Approx dates

To


On feet more than 2 hrs/day?

YesNo


Approx dates

To


On feet more than 2 hrs/day?

YesNo


Approx dates

To


On feet more than 2 hrs/day?

YesNo

Please list your relevant impairments and explain how they limit your ability to maintain full time work

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