Social Security and Disability Attorney in Houston and Austin Texas, SSDI Lawyer and Attorney, Representative

Social Security Disability Attorney in Houston, Austin, Texas

Hardy Law Firm specializing in disability, ssi, ssdi, social security and supplemental security income

Fill out this form and submit it for a free evaluation. We will call you back on the next business day. You will receive an auto-response email back from the evaluation form submission. If you do not, please call us at 1-800-947-0477 for assistance.

First Name:
Last Name:
Address:
City:
State:
Zip Code:

Phone:
Email:
Date of Birth:
Marital Status:	Single Married Divorced Widowed

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Your Name:
Your Phone:

Number of children under 19:
Household monthly income:

Claim Status:	Have not applied Have applied but have not received a determination Have applied and been denied At original claim At reconsideration At hearing stage
How many times have you previously filed?	1 2 3 4 5 or more
If denied, what level?	Initial Reconsideration Administrative Law Judge Appeals Council

Most recently denied
Type of claim?	SSI SSDI I don't know
Date you became disabled:
Have you worked 5 out of the last 10 years?	Yes No
Last date you worked
Are you working?	Yes No

Disability:

Physical / Mental
Limitations:

Conditions &
Symptoms:

Back Injury
Neck Injury
Hip Injury
Knee Injury
Foot
        Problems
Asthma
Hand
        Problems
Diabetes
Sleeping
        Problems
Depression         Disorder
Epilepsy
ADD
ADHD

Heart Problems
Poor Circulation
Nerve Problems
HIV
Hepatitis
Mental Illness
Anxiety Disorder
Panic Attacks
Bi-Polar
Multiple Sclerosis
Concentration/Memory Problems
Fibromyalgia

Are you being treated?

Yes No

Do you have an attorney?

Yes No

Is the injury work-related?	Yes No
Medications:
Other claims:	Workers Compensation Long Term Disability Personal Injury Medical Malpractice Other

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