Free 2 Minute Assessment

Name

How old are you?

Email Address

Phone Number

What city do you live in?

What is your current occupation?

Could you work at a different occupation? What would that job be?

Did this doctor encourage you to apply for disability?

How long have you been seeing this doctor?

Are you currently seeing a Physician for your conditions?

Yes No

What medical conditions prevent you from working?

Have you looked at your earnings report from Social Security?

Out of the last 10 years, have you worked at least 5 of those years full time?

Have you applied for Social Security Disability previously?

Yes No

What is the last date you worked?

Are you currently working?

Yes No

Education

Special education resource High School or GED Some college, no degree 4+ years college

Other Information

Honorable Discharge Less than Honorable Discharge I have a VA rating for disability

Frequency of Medical Treatment

Currently being treated by a Primary Care Physician who is a PA Currently being treated by a Primary Care Physician who is an MD Currently being treated by a Specialist No treatment within one year No treatment in the last three years

Is your Doctor cooperative in helping you with information for aclaim?

Yes No

Other important facts

Obesity with a BMI greater than 40 Use of a cane/walker/wheelchair History of a transplant Any cancer diagnosed within the last year?

Support

Do you have family support to help you emotionally? Do you have a spouse who is providing income/insurance? Did you need help from a family member to do this assessment? Are you able to read? Is English a second language for you?

Match Disability Law

Email: Support
Phone: 801-532-4556
Toll Free: 855-532-4556

Helpful Information

Other

Our Office

455 East 200 South
Suite 100
Salt Lake City, UT 84111

Monday through Friday
9:00 am – 5:00 pm

Saturday & Sunday
Closed

Contact Us For a Free Case Evaluation

Name

Address

Phone

Are you a current client?

Yes No

Have you worked 5 out of the last 10 years?

Yes No

Are you currently being treated by a doctor?

Yes No

Date of birth

Do you currently have an attorney *

Yes No

Questions for our team