Welcome! This consultation should only take about 10 minutes. We will review your information and contact you within the next business day. *

This consultation does not create an attorney-client relationship.
     
 
Thanks, what's your first name? *

 
Nice to meet you {{answer_TLl6}}. I'm Sarah with DSA.
Let's get started.

 
What's your middle name?

If none, please leave blank.
 
And what's your last name? *

 
What's your phone number? *

Please format like this: (111) 222-3333 or 111-222-3333
 
What is the best mailing address for you?

 
Street & Apartment or Unit # *

 
Zip Code *

 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
Great news! I've located your local SSA office. Please confirm option A with me, or if you have been to a different office, select other. *


 
What's your date of birth? *

 
If you a parent/guardian who is filling this out for a minor please let me know your full name. If not, just leave this blank (press enter).

* Remember to tell me only the applicant's information after this question.
 
What's your city and state of birth, {{answer_TLl6}}? *

 
What's your full social security #? *

Please format: XXX-OO-XXXX
 
What's your mother's maiden name? *

 
What's your father's name? *

 
Great! Thanks {{answer_TLl6}}. I've got your background information. Now, I just have a few questions about your disability."

 
When did you become disabled? *

 
{{answer_TLl6}}, what is/are your limitation(s)? *




 
Physical Limitations

 
Please tell me about your physical limitation(s). *

 
How badly does/do your physical limitation(s) affect you? *

 
Mental Limitations

 
Please tell me about your mental limitations. *

 
How badly do your mental limitations affect you? *

 
Mental & Physical Limitations

 
Please tell me about your mental & physical limitations. *

 
How badly do your mental & physical limitations affect you? *

 
Have you previously applied for disability benefits? *



 
Previous Application

 
Thanks, do you remember which type? *


 
About when did you apply for {{answer_mpXl}}, {{answer_TLl6}}? *

Your best guess works if you are unsure.
 
What happened with your {{answer_mpXl}} claim? *

 
Did you have an attorney? *



 
Thanks {{answer_TLl6}}. If you remember, what was your attorney's name?
*

 
What was the law firm name and city? *

 
Thanks for letting me know about your {{answer_xnrl}} limitations, {{answer_TLl6}}.

Next, let's go over your education and employment background."

 
When did you complete this education? *

Estimate if needed.
 
Are you currently in school? *



 
Education

 
What school do you go to? *

 
How many classes are you taking? *

 
Are any of your classes special education classes? *



 
Are you currently working? *



 
Current Employment Information

 
Where do you work? *

 
Is this *


 
About how much $ do you make per month? *


 
Past Employment

 
About when did you stop working? *

If you have never worked, just tell me your date of birth.
 
Could you let me know what stopped you from working? *

 
Great {{answer_TLl6}}! Next, let's go over some basic legal questions required by the Social Security Administration."

 
Have you had any history of drug or alcohol abuse or addiction? *



 
Thanks, could you tell me which? *


 
{{answer_t53T}} Information

 
About when was your last sober date? *

 
Do you have a sponsor? *



 
What's your sponsor's name ? *

 
What's your sponsor's phone number ? *

 
Do you attend any of these great support programs? *


 
I really appreciate that {{answer_TLl6}}. Just a few more questions left.

 
That was easy {{answer_TLl6}}. Just a few more questions left.

 
Have you ever been to jail or prison? *



 
Prison/Jail Information

 
What prison or jail? *

 
About when were you incarcerated? *

 
About when were you released? *

 
Are you currently on probation or parole? *



 
Thanks {{answer_TLl6}}. Lastly, I just need your emergency contact information and how you found out about us.

 
Who would you like us to contact in case of an emergency or if we can't get ahold of you with important information about your claim?

 
Full name of your emergency contact?

 
How are they related to you?

 
What's their best phone number?

 
If you know their address, could you let me know what it is?

 
Great, thank you {{answer_TLl6}}!

We would love to know... how did you hear about us? *


 
Is there anything I didn't ask that you would like to tell us?

 
Please review your contact information:


Name: 
{{answer_TLl6}}  {{answer_KJgl}}
Mailing Address: {{answer_Xbuf}}, {{answer_zo1R}} CA {{answer_cXzs}}
Phone #: {{answer_fFqU}}
Date of Birth: {{answer_YZGB}}
Social: {{answer_Vjuo}}

 
Did all your contact information look accurate? *



 
No problem, just let me know the correct information below and I'll make sure it is fixed *

 
Great, thanks {{answer_TLl6}}!

Since everything is good, please enter the last 4 digits of your social security # to confirm with me. *

 
How did we do today {{answer_TLl6}}! *

5 stars is great service!





 
Oops, please check that date again.

Thank you for choosing DSA {{answer_TLl6}}!
An attorney will review your information and contact you shortly to help explain your future claim options.

"Don't worry, we've got it from here."


(858) 500-3684
2534 State St. Suite 207 
San Diego, CA 92101
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