Free Case Evaluation

Please complete the evaluation form or call us for a free case evaluation. 248 788-6840


*Where do you live?City

*Telephone number(s)



*Education Level

*Have you ever attended Special Education?

If yes, Please describe

Work Information

Work History

*I have worked 5 out of the last 10 years?

*I am currently working?

If no, Last date worked?

*Describe Past work (in an 8 hour day)

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?

*Briefly describe disabling medical condition(s) and symptoms:

*Has your disability lasted at least one year?

*Will it last another 12 months?

*I see the Doctor every 3-6 months:

*Last appointment with Primary Doctor (dd/mm/yyyy)?

*I have medical insurance

*Do you see any Specialty Doctors?

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?

*Do you have difficulty sitting?

*Do you have difficulty using your hands?

SSA Claims

*Select One From Drop-Down

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?

I have filed an ALJ Hearing Appeal?

If yes, date of filing (mm/dd/yyyy)

Is your hearing scheduled?

If yes, please state the date of the hearing (mm/dd/yyyy)

*Do you have a representative or Attorney assisting you presently?

Referral Information

Name of Referral PersonFirst

Name of Referral Organization

Other Referral Source?