Social Security Disability Intake Form


Date of Initial Visit:	Month: Day: Year:
How did you hear about our office?:
Name:
Date of Birth:	Month: Day: Year:
Age:
Last Date Worked:	Month: Day: Year:
Employer:
Type of Work:
Your Contact Information
Address:	Street: City: State: Zip Code:
Telephone Number(s):	Home: Cell:
Emergency Contact Information (Friend or Family)
Name:
Relationship:
Address:	Street: City: State: Zip Code:
Telephone Number:
Disability Information
Have you been denied Social Security benefits?:
What are your Disability(s)?:
Are you currently seeing a doctor/hospital/clinic for treatment, if so please provide the name and address:
Are you currently taking any medication(s), if so please provide the name of the medication and what you take it for: