Feel free to complete the following Disability Questionnaire. DACR will review the information. If we are able to assist, we will contact you.
Full Name*:
Date of Birth*:
City, State, Zip*:
Telephone Number*:
Currently Working?:YesNoNa
Date You Last Worked:
Job Description:
When did you become disabled? (Onset Date)*:
Have you applied for Social Security disability?*:YesNo
If Yes, when did you apply?:
At what stage is your claim?:Don't KnowInitial ApplicationReconsiderationHearingAppeals CouncilFederal Court
Are you currently under the care of a doctor?*:YesNo
Please give us a detailed description of your disability*:
How did you hear about DACR, Inc?:Search EngineFriendOther
If through a Search Engine, what keyword(s) did you use to search?: