Client Questionnaire

Do You Have
a Claim?

Do not feel as though you have to go through this process on your own. Find out if you qualify to receive benefits now.
About SSD Eligibility
Proud Advocates
for the Disabled

Your choice in advocacy could be instrumental to the success of your case. Don’t put your financial benefits at risk!
How We Can Help You
No Fees
Until We Win

Our ultimate goal is to maximize your approval and minimize any complication. You pay no fees unless we win!
Get Started Today

Are you eligible for Social Security Disability benefits?

Before you take any further action on your claim for Social Security Disability, contact us at Golson, McCracken Inc. for a free consultation. We can review your situation with you in person or over the telephone to determine whether you are eligible, advise you of strategies to increase the likelihood that your claim will be approved, and help you determine how much your claim for benefits may be worth.

Please fill out the following form as best you can so that our representatives can better understand your unique situation.

Take the first step now by filling out the form below:

Full Name:*

Date of Birth:

Adult or Child?

Email:*

Address:*

City:*

State:*

Zip:*

Callback Number:*

Height:*

Weight:*

How did you here about us?

What prevents you from working?*

Highest Grade completed in school (any special education, repeated grades)

Can you read/write/do math? YesNo

All jobs you had in the last 25 years, and the last day you worked: (i.e. fired, retired, walked off, quit etc..)

Present income and source
Answer can be none as well, also include child support, food stamps etc.

Have you received Workers compensation, VA, short term, long term disability benefits? YesNo

Marital Status

If married: Spouse name? working? Getting Disability?

Tobacco use, Alcohol use, drug use:
(not prescribed medications, i.e.. cocaine, marijuana etc..)

Last time you saw a Doctor and why?

Are you taking prescribed medications? YesNo

Current Insurance:

Children and their ages:

Current and prior applications status/information:

Do you have someone representing you now? YesNo

Anything else you would like us to know?

Do You Have
a Claim?

Proud Advocates
for the Disabled

No Fees
Until We Win

Client Intake Form

Are you eligible for Social Security Disability benefits?

Do You Have
a Claim?

Proud Advocates
for the Disabled

No Fees
Until We Win

Social Security Disability
How Can We Help You?

Request Your
Free Case Consultation

You pay nothing unless we win for you. Tell us about your case today!

Call Today: (919) 294-4171

Do You Have a Claim?

Proud Advocates for the Disabled

No Fees Until We Win

Client Questionnaire

Client Intake Form

Are you eligible for Social Security Disability benefits?

Do You Have a Claim?

Proud Advocates for the Disabled

No Fees Until We Win

Social Security Disability How Can We Help You?

Request YourFree Case Consultation

You pay nothing unless we win for you. Tell us about your case today!

Call Today: (919) 294-4171

Do You Have
a Claim?

Proud Advocates
for the Disabled

No Fees
Until We Win

Do You Have
a Claim?

Proud Advocates
for the Disabled

No Fees
Until We Win

Social Security Disability
How Can We Help You?

Request Your
Free Case Consultation