Social Security IntakeHome//Areas of Practice//Social Security Disability Attorney//Social Security IntakeName(Required) First Middle Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country SSN(Required)DOB(Required) MM slash DD slash YYYY Age(Required)Phone(H)(Required)Phone(C)(Required)Place of Birth(Required)Mother's Maiden Name(Required)Referred By(Required)Case History(Required)Cause of Disability(Required)Does Your Currently Need to Be Appealed(Required) Yes NoIf yes, what is the date on your most recent turn down letterEducationLast Grade Completed(Required)Special Education(Required) Yes NoEmployment HistoryEmployer 1(Required)First Day Worked(Required)Last Day Worked(Required)Description of Duties(Required)Reason for Leaving(Required)Employer 2(Required)First Day Worked(Required)Last Day Worked(Required)Description of Duties(Required)Reason for Leaving(Required)Personal InformationHeight(Required)Weight(Required)Are you married(Required) Yes NoDo you currently have health insurance(Required) Yes NoIf no, how are paying for continued medical careDo you smoke(Required) Yes NoIf yes, please list frequency and amountDo you drink(Required) Yes NoIf yes, please list frequency and amountHave you used illegal drugs in the last fifteen years(Required) Yes NoIf yes, please list type and frequency of useHave you used prescription drugs not prescribed to you in the last fifteen years(Required) Yes NoIf yes, please list type and frequency of useHave you been incarcerated at any point in the last fifteen years(Required) Yes NoIf yes, please list reason for, length, and place of incarcerationMedical InformationMedical Information(Required)Doctor's NameDoctor's SpecialtyAddressTelephoneAre you currently receiving care from this Doctor Yes NoIf Yes, how often do you see this DoctorWhich of your conditions does this Doctor treat Add RemoveHospitalizationHave you been hospitalized for any condition(Required) Yes NoIf yes, please list the hospital's contact information, approximate dates you were there, and the reason for your hospitalizationName of hospital(Required)Name of hospitalAddressDatesReason for hospitalization Add RemoveMedicationsPlease list all medications you are currently taking(Required)NameDosageFrequency Add Remove
