Free Case Evaluation from The Law Office of Joy H. Hansler, Mesa, Arizona Attorney

Free Case Evaluation

INPUT

FREE CASE EVALUATION

If you provide complete answers, below, Ms. Hansler will contact you within 2 business days after receipt of the Evaluation Form to fully discuss your case.

If you are unable to provide complete answers, don't worry. Do the best you can and Ms. Hansler will phone to assist you with completing the Evaluation Form. All information is critically important for a full and competent assessment of your case.

If you need more immediate assistance, phone Ms. Hansler at (480) 246-8085, even if you are not a client. Ms. Hansler cares about your particular situation, and will briefly discuss your case with you without charge.

1. Claimant's Full Name - First, Middle Initial, Last:

2. Mailing Address (Include Apt or number):

2a. City, State, Zip Code:

3. Sex:

Male Female

4. E-Mail Address:

5. Phone Numbers:

6. Date of Birth:

7. Highest Education Level Completed:

8. Have you filed a claim for SS Disability (SSDI) within the last 18 months?

Yes No

9. If yes, is the claim still pending?

10. If still pending, where is your claim in the SSA system?

Initial   Administrative Law Judge

Reconsideration   Appeals Council

11. Was your claim denied?

Yes No

12. If yes, at what level was the denial

Initial   Administrative Law Judge

Reconsideration   Appeals Council

13. Are you represented by an attorney or a non-attorney representative?

Yes No

14. Have you stopped work?

14a. If yes, approximate date last worked.

15. Have you worked 5 of the last 10 years?

16. If yes, did you generally work full-time or part-time?

Part Time Full Time

17. What was your most recent job?

17a. Describe the physical and/or mental demands of this job.

18. Do you have any children under 18 living with you, for whom you have financial responsibility? If yes, list their names & ages.

2. Your Disability

19. Describe your disability in detail.

20. Describe how your medical condition prevents you from performing work.

21. Describe how your medical condition limits or affects your daily activities.

22. Please list any hospitalizations due to the above-described disability.

23. Any surgeries related to your disability? Explain.

24. What medications, if any, are you required to take for your disability?

24a. Describe any side effects from your medication(s).

25. How would you describe your pain (e.g. location, severity, frequency), if any?

26. Are you currently being treated by a doctor for your impairment(s)?

Yes No

26a. If no, why not?

27. If yes, does your doctor agree you are unable to work due to your disability? Explain.

28. Are you required to use any assistive devices (such as a walker or cane) due to your disabling condition? Explain.

28a. Do you have any visual or hearing limitations? Explain.

28b. Do you have any hand limitations? Explain.

28c. Do you have any restrictions in terms of walking or sitting? Explain.

28d. Is your injury work-related?

Yes   No

28e. If yes, did you file a Workers' Compensation claim?

Yes   No

29. Are you receiving or have you received Workers' Compensation?

Yes   No

3. CONCLUSION

30. Do you have any questions or comments? Please discuss here.

30a. I understand that by submitting this free case evaluation, I am not entering into an attorney-client relationship. As such, I will not rely on any response to this submission as legal advice.

Yes No

30b. I also understand I will not be charged for the information that I receive in response to this submission. Lastly, I acknowledge that any information transmitted via e-mail, such as this Case Evaluation Form, is not protected or secure

Yes No

MY CASE FOR EVALUATION

The information you obtain at this site is not, nor is it intended to be, legal advice. You should consult an attorney for individual advice regarding your own situation.

Copyright © 2009 by The Law Office of Joy H. Hansler. All rights reserved. You may reproduce materials available at this site for your own personal use and for non-commercial distribution. All copies must include this copyright statement.

1. Claimant's Full Name - First, Middle Initial, Last:
2. Mailing Address (Include Apt or number):
2a. City, State, Zip Code:
3. Sex: Male Female
4. E-Mail Address:
5. Phone Numbers:
6. Date of Birth:
7. Highest Education Level Completed:
8. Have you filed a claim for SS Disability (SSDI) within the last 18 months? Yes No
9. If yes, is the claim still pending?
10. If still pending, where is your claim in the SSA system?
Initial Administrative Law Judge
Reconsideration Appeals Council
11. Was your claim denied? Yes No
12. If yes, at what level was the denial
Initial Administrative Law Judge
Reconsideration Appeals Council
13. Are you represented by an attorney or a non-attorney representative? Yes No
14. Have you stopped work?
14a. If yes, approximate date last worked.
15. Have you worked 5 of the last 10 years?
16. If yes, did you generally work full-time or part-time? Part Time Full Time
17. What was your most recent job?
17a. Describe the physical and/or mental demands of this job.
18. Do you have any children under 18 living with you, for whom you have financial responsibility? If yes, list their names & ages.

19. Describe your disability in detail.
20. Describe how your medical condition prevents you from performing work.
21. Describe how your medical condition limits or affects your daily activities.
22. Please list any hospitalizations due to the above-described disability.
23. Any surgeries related to your disability? Explain.
24. What medications, if any, are you required to take for your disability?
24a. Describe any side effects from your medication(s).
25. How would you describe your pain (e.g. location, severity, frequency), if any?
26. Are you currently being treated by a doctor for your impairment(s)? Yes No
26a. If no, why not?
27. If yes, does your doctor agree you are unable to work due to your disability? Explain.
28. Are you required to use any assistive devices (such as a walker or cane) due to your disabling condition? Explain.
28a. Do you have any visual or hearing limitations? Explain.
28b. Do you have any hand limitations? Explain.
28c. Do you have any restrictions in terms of walking or sitting? Explain.
28d. Is your injury work-related?
Yes No
28e. If yes, did you file a Workers' Compensation claim?
Yes No
29. Are you receiving or have you received Workers' Compensation?
Yes No

30. Do you have any questions or comments? Please discuss here.
30a. I understand that by submitting this free case evaluation, I am not entering into an attorney-client relationship. As such, I will not rely on any response to this submission as legal advice.
Yes No
30b. I also understand I will not be charged for the information that I receive in response to this submission. Lastly, I acknowledge that any information transmitted via e-mail, such as this Case Evaluation Form, is not protected or secure
Yes No
MY CASE FOR EVALUATION