New Clients

If you are interested in retaining Chantal to help you with your disability case, please fill out our Potential Client Information Form, call us at (904)997-6077, or email at [email protected].

Potential Client Information Form

First and Last Name

Email Address

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Date of Birth

Medical Problems

Are you currently under a physician's care? Are you currently under a physician's care? Yes No

When was your last visit?

What is the last date you were able to work?

Have you applied for benefits? Have you applied for benefits? Yes No

If yes, have you received a determination? If yes, have you received a determination? Yes No

What was the date of your determination?

Describe the type of work you have done for the past 15 years.

Additional Remarks