Social Security Intake Sheet Form
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1
2INTERVIIEWING ATTY ________
CONFLICT CP: _____ ___INI: _______
DATE: __________
CONFLICT BXL: ______ INI: _________
BAILEY& GALYEN
Attorneys at Law
SOCIAL SECURITY INTAKE SHEET
Name _______________________________________________________________________________ DOB: _____________Sex: M ____F____
Last Name
First
Middle
Maiden
Place of birth___________________________________________________________________________________________________________
City
County
State
Country
Social Security Number: _____________________________ Drivers License Number: _______________________________ State_________
Address: __________________________________________________________________________________Apt. #______________________
City: __________________________________________ County: _______________________ State: __________ Zip: ____________________
Home Phone: (________) ____________________________________ Work Phone: (_______) _______________________________________
E-Mail Address: _____________________________________________________Cell Phone: (______) _________________________________
I authorize emails concerning my case.
I authorize emails of general interest from Bailey & Galyen.
I
(______)_______________________
authorize a follow up call regarding my consultation. If yes, please list a contact number.
Marital Status: ________________________
Spouse’s Name: ________________________________
What date did you apply for disability benefits? ______________________What date did you become disabled?______________________
What date did you last work? __________________________ What was your job? ________________________________________________
What dates were you denied benefits? (Enter all dates if multiple applications or multiple denials on same application)
______________________________________________________________________________________________________________________
Do you know what level of appeal your case is on? __________________________________________________________________________
Did you apply for both DIB and SSI or only one? ____________________________________________________________________________
Highest grade completed in school? ____________________________ any vocational training? _________________________
What type of work have you done for the last 15 years? ______________________________________________________________________
Did you receive any worker’s compensation benefits associated with your disability? _____________________________________________
How much per month and what dates? ____________________________________________________________________________________
What are your impairments or your diagnosis? ______________________________________________________________________________
Which doctors have treated you and are treating you for your disability?
Have you or family member been involved in any type of accident in the last two years?
Yes_______
No_______
Have you or a family member ever suffered any serious injuries after taking a prescription or non-prescription drug? Yes_____ No _____
Do you have need of legal assistance for any immigration matter? Yes_________ No _________
Purpose of visit today: __________________________________________ Do you currently have a will? Yes ________ No ________
HOW WERE YOU REFERRED TO US? (Circle one)
Office Sign
I’m a Previous Client
Bar Association
B&G Letter
TV Ad
Radio
Billboard
Website
In Mesquite
Phonebook: name of book ______________________ Friend: Name of Friend________________________________
An Attorney: Name of attorney ______________________________________
Other: _______________________________________________________
Bailey & Galyen Employee: Name of Employee __________________________________________________________________________________________
SOCIAL SECURITY INTAKE SHEET
REVISED 2-5-10
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