Services Free Case Evaluation Please complete the evaluation form or call us for a free case evaluation. 248 788-6840 *NameFirst Last *Where do you live?City State *Telephone number(s) Email *Age *Education Level ---Marginal Education (1st-6th grade)Limited Education (7th -11th grade)High School EducationCollege Education *Have you ever attended Special Education? YesNo If yes, Please describe Work Information Work History *I have worked 5 out of the last 10 years? YesNo *I am currently working? YesNo If no, Last date worked? *Describe Past work (in an 8 hour day) ---Sedentary – Lifted max 10lbs, sit 6-8 hours, full use of handsLight – Lifted max 20lbs occasionally, 10 lbs frequently, standing/walking 6 – 8 hours, occasional sitting,Medium – Lifted max 50 lbs occasionally, 25 lbs frequently, stand 6-8 hoursHeavy - Lifted max 100 lbs, occasional 50 lbs frequently, stand 6-8 hours Describe job titles of the work that you performed in the past 15 years with the last job first: Medical Information *Do you have a medical condition that interferes with your ability to work? YesNo *Briefly describe disabling medical condition(s) and symptoms: *Has your disability lasted at least one year? YesNo *Will it last another 12 months? YesNo *I see the Doctor every 3-6 months: YesNo *Last appointment with Primary Doctor (dd/mm/yyyy)? *I have medical insurance YesNo *Do you see any Specialty Doctors? YesNo If yes, Please list specialties. *What medical tests have you had? If you have not had any, please state none. What medical tests are you planning on having in the future? *List medications that you are taking. If you are not taking any, please state none. *Do you have difficulty walking and/or standing? YesNo *Do you have difficulty sitting? YesNo *Do you have difficulty using your hands? YesNo SSA Claims *Select One From Drop-Down ---I filed a previous claim but it was denied and I did not appealI have never filed a claimI filed a claim and it is presently in the process If claim is presently pending, please complete the following Date of Application filing (mm/dd/yyyy) Date of Application Denial (mm/dd/yyyy) I have a copy of my Notice of disapproved claim? YesNo I have filed an ALJ Hearing Appeal? YesNo If yes, date of filing (mm/dd/yyyy) Is your hearing scheduled? YesNo If yes, please state the date of the hearing (mm/dd/yyyy) *Do you have a representative or Attorney assisting you presently? YesNo Referral Information Name of Referral PersonFirst Last Name of Referral Organization Other Referral Source?