BEFORE APPLYING FOR SOCIAL SECURITY BENEFITS

Have as much of the following information as possible ready for your interview.

MEDICAL information:

1. Names, address and phone numbers of all doctors, hospitals and clinics 2. Dates seen 3. Names of medication/s you are taking

WORK history:

The type of jobs/work and dates you worked in the last 15 years before you became unable to work.

Please complete the Medical and Job Worksheet (SSA-3381) – it will speed up the appointment time.

Form SSA-3819 (2-2010) Use prior editions OVER

MEDICAL AND SCHOOL WORKSHEET - CHILD

Completing this worksheet will help you get ready for the interview. It will also speed up the interview. We may ask for additional information. If you need more space, use blank sheetsof paper.

A. Child’s height and weight.

B. Name, address, phone number, and relationship of another adult who helps care for the child and can help us get information about the child if necessary.

C. The child’s illnesses, injuries, or conditions.

D. When the child’s condition(s) began.

E. How they affect the child’s activities.

F. The child’s current grade, if in school.

G. Schools or preschools the child is currently attending, and any other schools he or she attended in the last 12 months.

NAME ADDRESS, ZIP CODE, andPHONE NUMBERDATES

ATTENDEDKIND(S) OF SPECIAL ED.

SERVICES (if any)

H. Current teacher’s name(s) and school.

I. School testing the child has had, such as tests for behavior or learning problems.

NAME OR KIND OF TEST DATE(S) NAME OF SCHOOL

J. Name of any school therapist the child is seeing or has seen (for example, speech, physical, or occupational) and the school name.

K. Hospitals, clinics, doctors, or therapists that have seen the child within at least the last 12 months.

NAME ADDRESS, ZIP CODE, and PHONE NUMBERPATIENT

I.D. NUMBERDATE

FIRST SEENDATE

LAST SEEN

L. Other agencies or programs that tested or examined the child, or that provided services (such as Headstart, Early Intervention Services or Special Education, Public or Community Health, Welfare or Social Service Agency, Mental Health/Mental Retardation Center).

NAME ADDRESS, ZIP CODE, and PHONE NUMBERKIND OF TEST OR SERVICE DATE(S)

M. Medicine(s) the child takes, and the doctor’s name if it is a prescribed medication.

NAME OF MEDICINE PRESCRIBED BY

N. All medical tests the child had or will have for his or her illnesses, injuries or conditions. (For example, hearing test, vision test, IQ testing, blood tests, breathing tests, x-rays.)

NAME OF TEST DATE(S) WHERE DONE WHO SENT CHILD FOR TEST

We have filed your Request for Hearing by an Administrative Law Judge

Please remember:

1. Although you may not get mail from Social Security, I will be receiving a monthly status report and I am glad to give you status any time. Just give me a call (you number here).

2. I could take as long as 12 months to get your case heard by a judge. Although, it has been averaging between 6 and 8 months and sometimes less.

3. Keep the lines of communication open. Call me if any of the following things happen.

a. Hospitalizations b. Arrested c. Job d. Married e. Move or get new phone number f. An attorney is retained

4. Continue seeing your psychiatrist with the Center, if you miss 3 to 6 months of appointments your clinical case is closed and I am obligated to withdraw my representation from your case with SSA.

5. Be honest with the psychiatrist about your symptoms. We need it all documented in your medical records.

Most importantly: PLEASE BE PATIENT with the process and with me. I am working very hard on your case and making sure that you have the best representation and the strongest case possible.

I will always be honest with you about your case.

We MUST meet as soon as we get notice of hearing as possible for prehearing preparations. As soon as you get your “Notice of Hearing”, call me so that we can schedule an appointment. DO NOT wait.

I WILL NOT represent you if I cannot do these preparations first.

HEARING QUESTIONNAIRE

Name: Date of Hearing:

SS# Case #

Please state your name and address:

Date of Birth: Age: HT WT

Normal WT? Weight Gain or Loss Y/N

What is your disabling condition?

Specific symptoms (Lack of concentration, nervousness, private, public, confusion, out of control, temper, in ability to complete tasks, unmotivated)

How long has this condition existed?

Are you currently in Treatment?

If so, Where?

What type of Treatment?

Are you currently taking medications?

Does the medication help?

Are there side effects? Y/N

Have you ever been hospitalized? Y/N

When?

Where?

How many times?

What type of treatment have you received?

How do you spend an average day?

How long can you sit?

Walk?

Stand?

How far did you go in school?

Can you read?

Can you write?

Where were you last employed?

What kind of job was it?

Was it your usual job?

Did you work full time?

What hours did you work?

Why did you work those hours?

Have you ever had any type of formal training for employment?

HOUSEHOLD EXPENSE WORKSHEET

The following information is needed to process your application or review for services:

Section I – check which ones describes you living arrangement:

own or buying my house paying rent living in another person’s household Live in a home/apartment that I do not pay rent or not owned Section II: How many people live in your household, including yourself? What is the average monthly cost for the following: Housing: $ Electricity $ Gas/Propane $ Water: $ Property Taxes $ Food $ How much do you, the applicant, contribute towards these expenses? How much do others in the household contribute towards these expenses? Any contributions from others who live outside of your household? Y/N If yes, please complete: Name of outside contributor: Expenses paid for:

Amount of money contributed towards these expenses? $ Agreement: If you agree with the above information, please sign and date below. Applicant: Date: Head of household Date:

1. BEFORE APPLYING FOR SOCIAL SECURITY BENEFITS2. SGA3. Medical and Job Worksheet - Adult - SSA 33813. Medical and Job Worksheet - Adult - SSA 3381_Page_13. Medical and Job Worksheet - Adult - SSA 3381_Page_2

4. Medical and School Worksheet - Child-SSA 38195. REQUEST FOR HEARING BY ALJ - IMPORTANT INFO.docx5A. REQUEST FOR HEARING BY ALJ - IMPORTANT INFO.docx5B. REQUEST FOR HEARING BY ALJ - IMPORTANT INFO

6. HEARING QUESTIONNAIRE7. HHSC - HOUSEHOLD EXPENSE WORKSHEET8. 5 STEP SEQUENTIAL EVAL PROCESS