SSA Consultation Form

    General Information






    City, State, Zip*

    Date of birth*

    Disability Information

    Is this a:

    Regular Disability CaseSSI CaseBoth

    Date you are telling SSA you became disabled*

    Have you already applied for social security disability?


    If You Have Applied:

    Have you been denied SSA benefits?


    If You Have Been Denied:

    What is the date of your last denial?

    How many times have you been denied on this application?

    How many previous applications for SSA disability have you filed?*

    Are you currently working?


    If you have stopped working, what is the date you stopped working?

    Which medical conditions or diagnoses are responsible for your disability?*

    If you have any MRIs, or other diagnostic imaging, which you believe support your disability claim, please provide the dates and what you believe they showed:

    Over the last 15 years, briefly describe all the job types you performed:*

    How far did you go in school (including any certifications you have earned):*

    Are you currently receiving medical care for all of your disabling conditions?


    If no, which conditions are you receiving medical care for?

    Please list the names of your doctors, how long you have been treated with them, and what medical condition they are treating:*

    If any doctors have told you either to apply for disability or said they will support you in a disability case, please provide the doctor’s name and when they told you this:

    In your own words, what has occurred to make you seek legal representation in your SSA case?*

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    How did you hear about Thomas & Thomas Law?