NEW CLIENT QUESTIONNAIRE INFORMATION ABOUT YOUFirst Name(Required)Middle InitialLast Name(Required)Nickname/Preferred NameSocial Security NumberDate of Birth(Required) MM slash DD slash YYYY Current Age(Required)Current Mailing Address(Required) Street Address City State ZIP / Postal Code Phone number(Required)Alternative phone numberEmail address Can you receive text messages on the number provided?(Required) YES NO How did you hear about us?(Required)I found you in the phonebook.I liked your google reviews.I did an internet search.A family/friend referred me.I saw you on TV.An attorney referred me.My medical provider (i.e., doctor, therapist, etc.) told me to contact you.OtherWhere was it that you heard about us?What is your marital status?(Required) I am married and I live with my spouse. I am married, but my spouse and I are separated. I am single. I am divorced. I am a widow or widower Does your spouse work?(Required) YES NO Please indicate how your spouse is paid:(Required) My spouse is paid an hourly rate My spouse is paid a yearly salary. My spouse makes $ an hour:(Required)works # hours per week:(Required)My spouse is paid $ a year in salary:(Required)When did your spouse pass away?(Required) MM slash DD slash YYYY Do you have any monthly income for yourself (i.e., not your spouse's income)?(Required) YES NO Describe your source of income (support alimony, rental income, disability payments, etc.) and the amount you receive per month:Do you have any assets (bank accounts, retirement accounts, stocks, bonds, property) worth more than $2,000.00 if you are single or $3,000 if you are married? YES NO NOTE: When answering this question exclude the home you live in and the car you drive to get to and from your doctor appointments?Briefly describe what assets you have and the approximate value :(Required)NOTE: Exclude the home you live in and the car you use to get to and from your doctor's appointmentsAre you or anyone in your household currently receiving any state assistance (i.e., food stamps, Medicaid/SoonerCare, TANIF)?(Required) YES NO Do you have any biological or adopted minor children who are under 18 years old?(Required) YES NO How many?(Required)123456+First & last name(Required)Age(Required) EDUCATIONAre you currently enrolled in any school/college?(Required) YES NO Describe your current school/college enrolment:(Required)The type of studies :The hours per semester you are attending :If you attend in person or remote learning : Add RemovePRESS + ICON TO ADD NEW ROWWhat is the highest level of education you achieved?(Required) I have less than an 8th grade education. I completed the 9th grade. I completed the 10th grade. I completed the 11th grade. I completed the 12th grade and received my diploma. I was enrolled in Special Education classes during high school. I earned a GED diploma. I graduated from high school and have some college credits, but do not have a college diploma. I have a received a college degree and diploma. I have a master degree or higher STATUS OF YOUR CASEHave you submitted an application for disability benefits with the Social Security Administration?(Required) YES NO When did you submit your most recent application for disability benefits?(Required)Have you been denied for disability benefits within the last 60 days?(Required) YES NO Please take a picture or scan all the pages your most recent denial letter(s) and upload it here. Drop files here or Select files Max. file size: 512 MB. CANNOT upload a picture, please text a copy of all the pages of your denial letter to our office at (918) 388-7752. WORK Are you currently working?(Required) YES NO Are you self employed or do you work for a company? I am self-employed I work for a company What is the name of the company you currently work for?When did you start working at your current company?How many hours do you work a week?What is your currently hourly rate or yearly salary?(Required)Are you receiving any accommodations from your current employer? YES NO Provide a list all the accommodations (i.e., more rest breaks, less hours, etc.) you receive from your current employer?What date did you last physically go into work?Were you fired/terminated, or did you quit/resign from your last job?(Required)I was fired/terminated from my last job.I quit/resigned from my last job.Why did you stop working?Are you currently looking for work?(Required) YES NO What kinds of work are you currently looking for?(Required)Are you planning to return to work in the next 12 months?(Required) YES NO Are you currently on Family Medical Leave Act (FMLA)?(Required) YES NO When were you placed on FMLA?(Required)Do you have a copy of your physician’s statement he/she completed putting you on FMLA?(Required) YES NO Are you currently on Short Term Disability (STD) or Long Term Disability (LTD) benefits through your company?(Required) YES NO PAST RELEVENT WORK In order to help us determine if we can help you prove you cannot do the work you have done in the last 15 years, answer the questions belowList each employer you have worked at in the last 15 years being sure to answer each question fully:(Required)COMPANY NAMEDATE EMPLOYMENT BEGANDATE EMPLOYMENT ENDEDJOB TITLEPROVIDE A BRIEF DESCRIPTION OF YOUR JOB DUTIESHOW MANY TOTAL HOURS DID YOU WORK A WEEKHEAVIEST WEIGHT LIFTED IN POUNDS(I.E., 10 POUNDS, 20 POUNDS, 50 POUNDS)MAXIMUM HOURS YOU STOOD/WALKED PER SHIFTMAXIMUM HOURS YOU SAT DURING SHIFT TO PER SHIFT Add RemovePRESS + ICON TO ADD NEW ROW MEDICAL List all conditions or diagnosis that impact your ability to work and give a brief description of the symptoms each condition is currently causing you on a day to day basis:(Required)ConditionDescription of Symptoms Add RemovePRESS + ICON TO ADD NEW ROWWhat is your height?What is your weight in pounds?What doctors are you CURRENTLY receiving treatment from? Please only list doctors you are currently in treatment for or have an upcoming appointment with:(Required)Clinic NameDoctor's NameDoctor's Type of Practice/Specialty(Etc)Date Treatment BeganNext Appointment DateFrequency of visitsConditions Doctor is treating Add RemovePRESS + ICON TO ADD NEW ROWWhat medications are you CURRENTLY taking:(Required)Name of MedicationDosageFrequency TakenDoctor who last prescribedReason for medication Add RemovePRESS + ICON TO ADD NEW ROWSince you became disabled have you had any testing or imaging (i.e., MRI, x-ray, colonoscopy, CT scan, EMG, Pulmonary Function Test, etc) completed?(Required) YES NO Because you answered YES, list all testing and approximate date performed since you became disabled(Required)Testing/ImagingApproximate Date Add RemovePRESS + ICON TO ADD NEW ROWDo you take your medications as prescribed and follow your doctor’s treatment recommendations?(Required) YES NO Because you answered NO, please explain why you are not taking your medications or following your doctor's treatment recommendation:Do you have physical conditions that impacts your ability to work? All my problems that keep me from working are mental only. I have both physical and mental problems that affect my ability to work. I have only physical problems that affect my work. How long can you sit at one time without having to get up or go lay down/recline?(Required)How long can you stand/walk at one time without having to lean on something, go sit down, or go lie down?What is your most comfortable position?What is the heaviest weight you can lift/carry without significant problems?Do you lay down or recline during the day?(Required) YES NO On average how much of your waking day do you spending laying down or reclining? When answering this question exclude the time you are in bed at night.(Required)0-10%11-20%21-30%31-40%41-50%51-60%61-70%71-80%Greater than 80%Do you have any problems reaching in front of you or to the sides?(Required) YES NO Provide examples of the problems you have reaching:Do you have any problems using your hands for fine or gross manipulation (i.e., writing, typing, grasping, handling small/large objects?(Required) YES NO Provide examples of the problems you have using your hands:Do you use an assistive device (i.e., cane, walker, wheelchair, crutches, etc.)?(Required) YES NO (i.e., cane, walker, wheelchair, crutches, etc.)?(Required) Cane One crutch Two crutches Walker Hand-push Wheelchair Motorized Wheelchair Where the above selected assistive devices prescribed by your doctor? YES NO Do you have a handicapped placard you hang in the window of your car (BLUE OR RED)?(Required) YES NO When was it issued?All my problems that keep me from working are mental only : YES I have mental problems that affect my ability to work that are diagnosed by a doctor and I take medications for them YES I have mental problems that affect my ability to work, but I do not yet have a diagnosis or take medications for them Do you have a current/history of abusing street drugs or alcohol? YES NO Describe your current/history of drug abuse in detail listing what you used, when last used, any rehab facilities you have attended:(Required)Do you have a medical marijuana card through the state? YES NO Are you currently using medical marijuana?(Required) YES NO Describe the frequency and amount of use and reasons for using(Required)Do you have a criminal history?(Required) YES NO Please describe the date of the charge, conviction, and any sentences you received:(Required)Since you became disabled have you applied for any Unemployment benefits through the state?(Required) YES NO When is the last date you received any unemployment compensation/payments?(Required)Have you ever been injured on the job and filed a worker's compensation claim?(Required) YES NO Are you currently drawing any worker's compensation payments?(Required) YES NO Has your worker's compensation claim been settled or resolved?(Required) YES NO Indicate the date the claim was settled or resolved and the amount of the settlement:(Required)Tell us anything else about yourself, condition, or disability claim that the above questions didn’t address, but you feel is important for us to know:Untitled
