Alliant Disability — Client Intake (Post-Acceptance)

Post-Acceptance Intake

Client Intake Form

6900 Tavistock Lakes Blvd, Suite 400 · Orlando, FL 32827
(689) 208-4288 · www.alliantdisability.com

Welcome to your Alliant Disability Client Intake Form.
We need this information to file your application for Social Security Disability Insurance (SSDI) benefits. Any delay in completing this form may delay your application — and could result in a delay in receiving additional back pay if your claim is approved.

Please complete as much information as possible before submitting. You can save your progress at any time and return to finish later — your answers are automatically saved. If you need help completing this form, please call us at (689) 208-4288.

Client & Case Information

Please review and complete all fields. Fields highlighted in blue were pre-filled from your initial screening — please verify they are correct.

First Name

Middle Initial

Last Name

Social Security Number

Date of Birth

Place of Birth (City, State)

Phone

Mailing Address

City, State, ZIP

Matter Number

Case Manager

Program Type

Language & Citizenship

Preferred Language

U.S. Citizen?

Yes No

If No — Lawfully admitted date

Name at Birth (if different)

Other SSNs Used (if any)

Disability Information

Date condition became severe enough to prevent work

Last Day Worked

DLI Date (Date Last Insured)

SSA Claim Number (if filed)

Still unable to work?

Yes No

If No — Date became able to work

Condition related to work injury?

Yes No

Blind or low vision?

Yes No

List all disabling conditions

Prior applications / denials

Marital Status & Family

Ever been married?

Yes No

Dependent children (unmarried, under 18; or 18-19 in school; or disabled before 22)

Child under age 3 in year with no earnings?

Yes No

Dependent parent receiving 1/2 support from you?

Yes No

If Yes — Parent name, address, SSN

Work History & Earnings

Please list all jobs you have held in the last 5 years, starting with the most recent. Include part-time and self-employment.

Total earnings LAST YEAR

Total earnings SO FAR THIS YEAR

Self-employed this year or last year?

Yes No

Type of business (if self-employed)

Most Recent Employer

Employer Name

Employer Address

Job Title / Duties

Work Began (MM/YYYY)

Work Ended (MM/YYYY)

Previous Employer

Employer Name

Employer Address

Job Title / Duties

Work Began

Work Ended

Received money from employer after becoming disabled?

Yes No

If Yes — Amount and type (sick pay, vacation, etc.)

Medical Providers & Treatment

Please list every doctor, specialist, therapist, hospital, or clinic that has treated you. The Social Security Administration will contact each provider listed to request your medical records.

Primary Treating Provider

Provider / Facility Name

Specialty

Address

Phone

First Visit

Last Visit

Next Appointment

Conditions Treated / Chart Numbers

Current Medications

Medication 1

Name

Dosage

Prescriber

Treats

Medication 2

Name

Dosage

Prescriber

Treats

Include all prescription medications, over-the-counter medications, vitamins, and supplements you currently take.

Remarks & Additional Notes

Additional information or explanations needed for any item above

Completed by

Case Manager Client Both

Date Completed