Thank you for contacting Aplin Disability! Please read the privacy policy below, and then fill out this form in its entirety prior to our consultation. Please note that several of these questions help us determine early on if your case is a good fit for the firm and how best to represent you and guide the next conversations. We take pride in getting to know you as a client, but it starts with you. Thank you!

Privacy Policy

All information received from a client is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.

Your Social Security Number and other personal information will only be used in the event that you hire the firm to represent you in your legal matter, and then only when necessary in limited use during the course of your case.

Social Security Numbers are most often used to positively identify parties. Most courts require Social Security Numbers of all parties in a case. Some other examples of how this information may be used include:

initial service
in court orders
in required reports or other documents filed with the State

If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!

Contact information

Prefix

First name *

Middle name

Last name *

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

THANK YOU

Thank you so much for completing this intake questionnaire. This information will be extremely helpful in evaluating your case. We will contact you as soon as possible with any updates.

Please click the SUBMIT button below when you have finished answering all questions.

Contact information

Is the name you entered for contact your legal name?

Are you a veteran?

Are you receiving, or are you applying, or have you received any of the following benefits in the last year?

Physical Problems?

Do you currently drink alcohol?

Do you currently use marijuana, cannabis, THC, or CBD products for medical or recreational use.

Do you currently use any other drugs or substances that have not already been listed, whether prescribed, non prescribed, or recreational?

Do you see any of the following or have you been seen in the last 2 years by any of the following

Have any of your healthcare providers told you that changes to your lifestyle, habits, or daily activities could improve or reduce your symptoms?

Do you follow your providers advice?

Does any of the following apply to you?

Mental Health Problems?

Have you received Social Security Benefits before (SSDI or SSI)?

Date of Birth

Preferred Contact Method

Are you currently employed?

Gender Identity

Have you used other representation?

Have you applied before?

Do you have an SSA.gov account?

How were you referred to our law firm?

Please acknowledge that you have read and hereby accept the above privacy policy regarding use of my personal information by typing your full legal name below

THANK YOU

Please attach any SSA decisions or notices you have received recently, please note there will be other opportunities if you are accepted as a client to upload other documents, ie: medical docs, doctors letters, VA documentation etc.