NEW CLIENT - SOCIAL SECURITY

BACKGROUND

Please take your photo and upload it here. It will be saved to your case file.

Max. file size: 50 MB.

Please attach your denial letter. If you do not have it handy, please email it to newclientinfo@ghitterman.com before your appointment.

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Appointment Date and Time

How were you referred to us?

If you selected Friend/Family Member, Event, Attorney, Community Organization, or Other for the prior question, please specify where you heard about us.

Which of the following are you seeking (check all that apply)?

Social Security Disability Insurance (SSDI)
Supplementary Security Income (SSI)

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Alternate Phone

Email Address

Date of Birth

Primary Language

Need Interpreter?

Read English?

Write English?

Do you have a smart phone?

Do you use texting?

Emergency contact (Name, Relationship, Cell Phone)

Mother's Maiden Name

*The Social Security Administration requires this information.

City of Birth

*The Social Security Administration requires this information.

Do you have an attorney? If so, for how long and why are you seeking additional legal counsel?

CLAIM INFO

Are you currently or have you received SSDI/SSI benefits in the last year?

If yes, please provide the date of last check

If no, please answer the following: Date applied for SSDI /SSI

Date (s) of denial letters

On your application, what date did you state as the day you became unable to work?

What date did you last work?

Do you have a hearing scheduled, and if so, when?

Have you already had a hearing, and if so, when?

Have you ever worked?

If yes, why did you stop working?

Why can’t you work now? (describe your limitations)

All medical conditions/diagnosis affecting your ability to work

Name, Address, phone and email address for your family doctor

Name, address, phone number, & specialty of each health care provider you have seen

CURRENT MEDICATIONS

Name of medication , prescribing doctor, condition treating, side effects, if any

Since you applied for benefits, ha s your condition /diagnosis changed?

If yes, please describe how your condition/diagnosis has changed

EMPLOYMENT INFO

Prior employment (over the last 15 years): Employer

Job Title

Dates of employment from

To

Duties

Prior employment (over the last 15 years): Employer

Job Title

Dates of employment from

To

Duties

Prior employment (over the last 15 years): Employer

Job Title

Dates of employment from

To

Duties

Prior employment (over the last 15 years): Employer

Job Title

Dates of employment from

To

Duties

EDUCATION

What was the highest grade you completed in school?

If you left school before completing high school, did you earn a GED?

Please identify any college, vocational or certificate programs that you have attended , the type of training and whether you completed the program

Social Security

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BACKGROUND

CLAIM INFO

CURRENT MEDICATIONS

EMPLOYMENT INFO

EDUCATION