Please answer the following questions:
Someone from our office be contacting you shortly so that we may help you with your Social Security Disability claim.
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Case Information
When did you or your child become disabled?
Impairments/Disability Please describe your disability:*
Is a doctor currently treating you?*	Yes No

Have you worked 5 out of the last 10 years?*	Yes No

Are you working now?*	Yes - Full Time Yes - Part Time No

Have you applied for Social Security Disability?*	Yes No

Are you currently receiving benefits from Social Security?*	Yes No

Do you agree with the Terms and Conditions of this site?*	Yes


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