• Give me your phone number, email and name
  so I can tell you my opinion of your chances of getting benefits:
   

  Name

  E-mail  **Important**  Be by your telephone as I call back sometimes within minutes of getting this form. Phone Number I'm going to telephone you.  WHEN WILL YOU BE BY YOUR TELEPHONE TO PICK IT UP AND TALK?

• Where is your application in its journey before the Social Security Administration? 
  Choose one of the following options (click onto the down-arrow):

          I haven't filed a claim yet. Filed but no decision by SSA yet. Denied at intial application Denied after Appeal/Reconsideration Waiting for a hearing before a SSA judge

• How old are you?

• Please write  briefly what your medical doctors and others diagnosed you with (Pretend you're the doctor talking and tell me what HE-the Doctor would say.  Example-disk disease, arthritis, Bi Polar, etc.)

  
  

• Explain why your medical conditions prevent you from working-(both your last job and the easiest job you've held in the past 15 years)?

  
  

• Tell me what TYPES of jobs you have done in the last 15 years (example, tell me "what you did", secretary using computer and filing, lumberjack moving heavy logs-climbing trees, etc.)?  (this helps me prove to SSA that you can't do your old jobs so tell me HOW HARD your old job was!)

  
  

• You last worked full time (pick one):

  Still working A few months ago One year ago Two to Five years ago Over Five years ago

   

  
  

• **I can't tell you what I think of your case unless you give me your phone number or email (go to top of form to give me that)**

  You can also telephone me at 503.639.6666 or toll free 866.350.6772 I'll look over your information and get right back to you.  MAKE SURE YOU TELL ME WHEN YOU WILL BE BY YOUR TELEPHONE WITH YOUR ANSWERING MACHINE TURNED OFF! Thanks for writing and "hang in there!"  Daniel Alan Bernath Attorney at Law