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Social Security Disability Contact Form

If your application for Social Security Disability benefits has been denied, you have the right to appeal. An attorney can assist you in the appeals process. To find out how our firm can help, contact us to schedule a consultation and case evaluation with a Social Security Disability attorney.

Texas SSD Attorneys

If you cannot work because of a physical impairment or mental impairment, or you are the parent or guardian of someone who is disabled, call the Social Security Disability lawyers of Coats & Todd at 800-856-1031.

Based in Richardson, Texas, we represent people with physical and mental impairments in the Dallas-Fort Worth area, throughout Texas and nationwide.

Thank you for contacting The Law Offices of Coats & Todd. Your message has been sent.

Call us now

or use the form below.

Social Security Disability Contact Form

Personal Information

Full name

Maiden name

Other names used

E-mail address

Phone number

Business phone

Cell phone

Address

City

State

Zip

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?

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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