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Sheff Law Offices, P.C.
10 Tremont Street, 7th Floor
Daniel Webster Suite
Boston, MA 02108
Phone: (617) 227-7000
Fax: (617) 227-8833

Free Consultation

Your Name:	*
Your Telephone Number:	*
Your Email Address:	*
If you are not the claimant, please tell us the best way to reach you:
If you are not the claimant, please tell us your relationship to the person you are inquiring for:

Please note, we cannot properly consider your
case without a valid e-mail address.

Claimant's Name:	*
Claimant's Telephone:	*
Claimant's Email Address:	*
*Please leave blank if you are the claimant
Claimant's Address:
City:
State, Zip:
Telephone Number:
Cell (Mobile) Phone:

If you are the claimant, please tell us the best way to reach you:
Your Current Age:

Work History:

Are you presently working? Yes No

*If Yes, please note, we cannot assist you if you are working

When did you stop working?

In the last 7 years, please tell us about your work activity:

Year Full Year Part of the year Did not work at all

2007

2006

2005

2004

2003

2002

2001

Social Security Claim Status:

Have you applied for Social Security Disability (SSDI) in the last 18 Months?	Yes No
If yes, is the claim still Pending?	Yes No Not Sure

If yes, at what level?
Was your claim denied?	Yes No Not Sure
If yes, at what level?
Give us the approximate date of your last denial:

Please describe your disability:

Please tell us some of your
physical and mental limitations:

Conditions & Symptoms:
Back Injury Neck Injury Hip Injury Knee Injury Foot Problems Asthma Bronchitis Sleeping Problems Depression Disorder Epilepsy ADD ADHD	Heart Problems Poor Circulation Nerve Problems HIV Hepatitis Mental Illness Anxiety Disorder Panic Attacks Bi-Polar Multiple Sclerosis Concentration Problems Memory Problems

Is a doctor currently treating you?	Yes No
If no, why not?
Is the injury work-related?	Yes No
If Yes, did you file a Workers Compensation Claim?	Yes No
Are you receiving or have your Received Workers Compensation?	Yes No
Do you have an attorney presently assisting you in a Social Security Disability (SSDI) claim?	Yes No

If Yes, why are you seeking our assistance?

Please list the medications you are taking:

Are you receiving any other types of benefits
listed below? *Please check all that apply:

Long Term Disability
Early Retirement From Social Security
Widow's Benefits From Social Security
Personal Injury Settlement
Medical Malpractice Settlement
Other

How did you become disabled?
*Please check all that apply

Natural Causes
Sickness/Illness/Disease
Medical Malpractice
Car Accident
Injury or Accident
Medication or Product
Other

If you chose "Medical Malpractice," "Car Accident,"
"Injury or Accident," "Medication or Product," or "Other"

Date of incident:	*
City where incident occured:	*
State where incident occured:	*
What was the date of the incident?
What city did the incident occur in?
What State did the incident occur in?

Please tell us what happened. Be sure to include
all the facts including who was at fault and why:*

To Better Serve You:

Please tell us how you found us? If "other" please specify.

Please specify how you found us (if other than above):

If you found us using a search engine,
please tell us which search engine?

Please tell us exactly what terms you typed into the
search engine to find us? (i.e. Personal Injury Lawyers)

I understand that by filling out this free consultation form I am not forming an attorney client relationship. I understand that I may only retain an attorney by entering into a fee agreement and that by submitting this form I am not entering into a fee agreement. I understand that not all submissions may receive a response.
Yes No

I agree that the above does not constitute a request for legal advice. I agree that any information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. I agree that if this matter requires advice regarding my home state, local counsel may be contacted for referral of this matter. I understand that email is not secure and thus I am not forming a confidential relationship.
Yes No

I have read and agree with the TERMS AND CONDITIONS
Yes No

By Clicking the box below, I agree to submit my case for a free case evaluation:

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» Americans with Disabilities Act 1990

» Download Social Security Forms

» Free Case Evaluation

» Quick Facts: Americans with Disabilities Act

» Social Security Benefit Eligibility Screening Tool

» Social Security Disability Frequency of Reviews

» Social Security FAQs

» Social Security: Mental and Physical Disability List

» SSDI or SSI Which One Do You Qualify For?

» SSDI: Work Incentives and Special Cases

PHARMACEUTICAL & DANGEROUS DRUG UPDATE:
Fosamax - Jaw Death & Osteonecrosis
Ketek - Liver damage
Fentanyl Transdermal System - overdose leading to death
Trasylol - (aprotinin injection) kidney problems, heart attacks and strokes
Qui Tam - Medicare Fraud
MRI Skin Disease - Gadolinium MRA linked to NSF
Zometa - Jaw Osteonecrosis