Considering Applying for Disability Benefits?

Let Us Help.

Please take a few minutes to fill out this confidential questionnaire. Your answers will help us understand your situation and see how we might be able to assist you with Social Security Disability (SSDI), Supplemental Security Income (SSI), or Cash Assistance Program for Immigrants (CAPI) benefits.

Filling out this form does not create an attorney-client relationship.
We will keep your information confidential. Our website uses secure submission (HTTPS).
After you submit the form, our attorneys will review it and contact you within one business day to discuss the next steps.

If you have trouble with the form, please call us at (818) 244-8843.

Name

First Name

Last Name

Phone

(###)

###

####

Social Security Number

Note: We need your SSN to check your work history for Social Security benefits and to properly identify you with the Social Security Administration. This form is submitted securely. If you are not comfortable providing it now, you can give it to us when we speak. However, providing it now can speed up our review.

How did you hear about us?

Which benefits are you primarily interested in applying for? (Check all that apply, or "Unsure")

Please list your main physical or mental health conditions that prevent you from working.

Be as specific as you can, e.g., "Herniated disc in lower back," "Severe depression and anxiety," "Diabetes with neuropathy"

When did your health conditions first prevent you from being able to work (or severely limit your ability to work)?

If you are unsure of the exact date, you may provide an approximate date.

YYYY

Are you currently receiving medical treatment for your conditions?

Yes

Please list the names of up to 3 main doctors, clinics, or hospitals where you have received treatment for your conditions in the last 1-2 years.

Please provide addresses and phone numbers (if available).

Are you currently taking any prescription medications for your conditions?

Are you currently working?

Have you worked at least 5 out of the last 10 years?

This helps determine SSDI eligibility.

List all full-time occupations you've performed in the last 5 years.

E.g., "Construction worker," "Office clerk," "Retail sales associate"

What is the highest grade of school you completed?

Have you ever applied for Social Security disability benefits (SSDI or SSI) or CAPI before?

Do you currently have income from any source?

E.g., part-time work, workers' comp, state disability, help from family, etc.

Do you own your home or rent?

Excluding the home you live in and one car, do you (and your spouse, if married and living together) have cash, bank accounts, stocks, bonds, or other assets totaling more than $3,000 (for an individual) or $4,500 (for a couple)?

We use this information to help determine SSI eligibility

Yes

Are you a U.S. Citizen?

Yes

Is there anything else you would like to tell us about your situation or your health conditions?

Call or Visit

(818) 244-8843

815 South Central Avenue, Suite 33
Glendale, CA 91204
T: (818) 244-8843 F: (818) 244-8834

Monday – Friday: 9AM – 5PM
Saturday - Sunday: Closed

EMAIL

shahinianlaw@gmail.com