Disability Evaluation Form

Fill out Step 1 & 2 form fields, agree to the Disclaimer, and click Submit. Make sure that all fields marked (Required) are filled out.

Step 1: Case Information

Is applicant currently receiving Social Security Benefits? (required)
YesNo

Does applicant expect to be out of work for at least 12 months? (required)
YesNo

Does applicant have an attorney helping them with this case? (required)
YesNo

Is applicant receiving treatment from a doctor? (required)
YesNo

What is applicant's disability? (required)

Step 2: Contact Information

Full Name (required)

Email (required)

Phone (required)

Disclaimer Agreement
By submitting this form you agree to the posted Disclamer and that it does not constitute legal for form an attorney-client relationship. Hodges Trial Lawyers does not agree to represent you or take your case simply because you complete this form or email the firm. Furthermore, Hodges Trial Lawyers does not wish to represent anyone in a jurisdiction where this website fails to comply with all applicable laws and ethical rules.
Do not use the form to submit confidential, privileged, or sensitive information. The information submitted on this form is not privileged. As with any information submitted over the internet, there is a risk that the information could be intercepted, viewed, or retrieved by a third party.

I Agree to this Disclaimer (required)