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Social
Security Disability Inquiry Form - Child |
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* Required |
| Child's
Name* |
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| Child's
Soc. Sec. No.* |
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| Child's
Date of Birth* |
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| Your Name* |
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| Relationship
to Child* |
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| Phone
Number(s)* |
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| Address |
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| E-Mail* |
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| Child's
Grade |
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| Is Child In
Special Education?* |
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| Child's
School |
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| School
Address |
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| School
Telephone |
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| Teacher's
Name |
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| At What
Level Is Your Child's Case?*
Remember: 60-Day Deadline
to Appeal Denied Cases
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| If
The Hearing Is Scheduled, Tell Us: |
Date:
Time:
Judge: |
Location:
Hartford
New Haven
Springfield |
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Where Did You
File Your Child's Case? |
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Massachusetts
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| Click Which
Of These Conditions Your Child Has |
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| Please Tell
Us About Any Other Medical Problems Your Child Has |
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Click Which
of These Hospitals Your Child Has Gone To |
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Massachusetts
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| Tell Us
Your Child's Doctors
Include Name, Address, Telephone |
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| Tell Us
Your Child's Prescription Medications |
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Please include the area codes for
your phone number(s).
Please note that with this form you are only
sending us information.
To hire us as your attorney you must sign a
contract with us to represent you in this matter.
Thank you for sending us this information.
