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Disability Benefits Intake Questionnaire

Please tell us about your Social Security Disability (SSDI) or SSI situation so we can see how we may be able to help. Strict deadlines can apply after any letter from Social Security — some as short as 10 days — so please answer as completely as you can. There are no wrong answers, and you can skip anything you are not sure about.

985-612-7220 | stephen@aertkerlegal.com | www.aertkerlegal.com | 229 N. Vermont St., Covington, LA 70433
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PLEASE READ FIRST. Submitting this questionnaire does not create an attorney-client relationship and does not by itself make you a client or prospective client of the firm. No representation begins until the firm has checked for conflicts of interest and you and the firm have signed a written engagement agreement. Do NOT include your full Social Security number anywhere on this form. We will collect it securely later if the firm takes your case. Please name any employers you worked for in the last 5 years and any lawyer or advocate who has represented you on this claim, so the firm can check for conflicts of interest. Information you submit is handled confidentially consistent with Louisiana Rule of Professional Conduct 1.18.
1
Contact Information
Please tell us who you are and the best way to reach you.
Your age directly affects the disability rules that apply to your case.
2
Where Are You in the Process?
Pick the choice that best matches your situation right now. This tells us which deadlines may apply to you.
Deadlines run from this date — most appeals must be filed within 60 days, and if your benefits were stopped, some rights expire in as little as 10 days. Please answer as precisely as you can.
It's okay if you're not sure — we will figure it out with you.
3
Work Status Today
Tell us whether you are working right now. Honest answers here help us protect your claim.
Social Security applies an earnings cutoff that changes each year; your answer helps us screen it.
Your best guess is fine.
4
Work History (Last 5 Years)
Social Security now looks back only 5 years at your past work. Jobs you held for under 30 days generally don't count. Please start with your most recent job. Listing your employers also lets us check for conflicts of interest.
Your most recent job.
If you still work there, leave blank.
Leave blank if you had only one job.
Leave blank if it doesn't apply.
5
Medical Conditions
Your medical records are the heart of a disability case. Tell us what you are dealing with and who treats you.
Include physical and mental health conditions. Don't worry about exact medical terms.
6
Daily Limitations
Describe how your conditions limit you on an ordinary day. Everyday examples help more than medical terms.
7
Other Benefits & Income
Other benefits can affect a Social Security claim, so we ask about each one. Simple yes-or-no answers are all we need here — no dollar amounts.
A workers' comp claim or settlement can change your Social Security amount — and settlement wording matters. Tell us about any WC claim even if it's closed.
This is disability insurance through a job or bought on your own.
Drawing unemployment while claiming disability isn't automatically disqualifying, but it needs careful handling — tell us honestly.
This only matters for SSI. Yes or no is all we need for now.
Again, just for SSI screening — no values or details needed.
8
Prior Applications & Representation
Earlier applications and anyone who has helped you before can affect what we do next.
Please give the name so the firm can check for conflicts of interest.
If a hearing is scheduled, contact us immediately — evidence must be submitted at least 5 business days before it.
9
Documents
Letters from Social Security tell us your deadlines, so they are the most helpful documents you can share.

If you can, attach up to three documents: (1) the most recent denial or notice letter from Social Security, (2) any award or overpayment letter, and (3) a list of your medications or doctors. PDF, Word, or image. Photos of letters taken with your phone are fine. You may bring or email additional documents to your consultation.

Up to ~7 MB total across all files. For larger or highly sensitive files, please email them separately or bring them to your appointment. Please do not upload anything showing your full Social Security number.

10
Anything Else & Submission
You're almost done. Add anything we didn't ask about, then submit.

For questions about this form or to reach our office, contact 985-612-7220 or stephen@aertkerlegal.com.

Learn about our Disability practice

This questionnaire is confidential. Communications from prospective clients are protected under Louisiana Rule of Professional Conduct 1.18. Stephen C. Aertker, Jr. is licensed in Louisiana and Mississippi.