Today's Date

Your Name

Your Address

Your Phone

Are you married?

Yes No

Do you have any dependent children?

Yes No

If so, how many?

Date of Birth

What is the highest grade in school you completed?

grade

Have you worked five (5) years out of the last ten (10)?

Yes No

What type of work did you do?

Approximate date of your last day of work?

Please list your disabilities, with medical diagnosis if possible, or your best descriptions of your symptoms:

Have you ever used illegal drugs, or abused prescription or other drugs?

No Yes

If so, have you ever received drug treatment?

Not Applicable Yes No

Are you still using?

Not Applicable Yes No

Have you applied for benefits from the Social Security Administration?

Yes No

If so, what is the status of your claim, please check one:

Waiting for application decision

Application denied; have not
      requested reconsideration yet (you
      have 60 days from date of denial
      in which to appeal)

Waiting for reconsideration decision

Reconsideration denied; have not
      requested hearing yet (you have
      60 days from date of denial in
      which to appeal)

Waiting for hearing

Other

If other, please list the status of your claim here:

What is the date stamped on your most recent denial? (type "N/A" if Social Security has not denied your claim)

Do you have a workers' compensation case?

Yes No

If so, has it been settled?

Not Applicable Yes No

If it is settled, I will need to see a copy of the settlement contract before accepting your case.

What is the name and address of your workers' compensation attorney?

Were you referred to this firm by an attorney?

Yes No

If so, what is the name of the attorney and the city and state that he/she practices in?

If not by an attorney, how did you hear about the firm?

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