Other names used
Incident Street Address
Please describe all of your injuries, illnesses, symptoms, and disabilities, whether physical, mental, or emotional.
How do your medical problems limit your daily activities?
Are you able to work?Yes No
Are/were you self-employed?Yes No
What is your age?
What is the last grade you completed in school?
Do you have a high school diploma or its equivalent?Yes No
Do you attend a vocational school or college or program?Yes No
If so, what did you study and did you earn any certifications or licenses?
Did you attend college?Yes No
If so, what did you study and did you earn any degrees?
Please describe any graduate study or advanced or professional degrees.
Do you possess any vocational or professional licenses?
Approximately how long have you been in the workforce? (years)
Describe briefly the types of work you have performed.
If you are able to work, how many hours can you work per week?40 hours or moreBetween 20 and 40 hoursBetween 10 and 20 hoursLess than 10 hours
Have you filed for disability benefits for the medical problem/s described above?Yes No
Have you been turned down for benefit payments based on the medical problem/s described above?Yes No
Have you appealed a Social Security decision that denied you benefits for the medical problem/s described above?Yes No
Other information or concerns?
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Attorney Marjorie Drake represents people throughout Hartford Connecticut, and surrounding areas including New Britain, Waterbury, Farmington, West Hartford, Middletown, Hartford County, Tolland County, and in the Farmington Valley.