Alliant Disability — Client Intake Screening

1 Client Information

0 pts ▾

Client Full Legal Name * Must match SSA records exactly

Date of Birth *

Age (auto)

Enter date of birth

State of Residence

Best Phone Number

Benefit Type Being Sought * SSDI requires work history; SSI does not

2 Medical Conditions

0 / 18 pts ▾

Primary Condition Category *

Specific Diagnosis / Diagnoses List all diagnosed conditions if known

Suggested Case Strength Tier (auto)

Select condition category above 0 pts

Override Tier (if needed) Override only if specific listing review changes assessment

How many separate disabling conditions does the client have? * Count distinct diagnosed conditions (e.g., back pain + depression = 2)

Does the client have BOTH a physical AND a mental health condition?

3 Medical Records & Treatment History

0 / 36 pts ▾

What type of medical testing has the client had? * This is the strongest predictor of a favorable outcome

How long has the client been under consistent medical treatment? *

Total number of doctors/providers seen in the past 2 years * Count all providers seen at least twice

Number of those who are specialists * Neurologist, cardiologist, orthopedist, psychiatrist, oncologist, etc.

Provider strength (auto)

Enter provider counts above 0 pts

4 Physical Ability & Limitations

0 / 10 pts ▾

What is the most physical work the client can do on a typical day? *

Are there limitations beyond just physical lifting/walking? Examples: pain, difficulty concentrating, anxiety in public, balance, vision, sensitivity to noise/chemicals

5 Work History & Background

0 / 37 pts ▾

Current work status *

Earnings status (auto)

Not working — below earnings limit 5 pts

Most recent job title(s) in last 5 years

How physically demanding was that job? *

Vocational profile (auto)

Select physical ability and past job above 0 pts

Highest level of education completed *

English proficiency

6 Application Timeline

0 / 22 pts ▾

Last date client was insured for SSDI benefits (SSDI only) Leave blank for SSI-only cases. This is the "coverage expiration date" for SSDI.

SSDI insurance status (auto)

Enter DLI date or select SSI-only 0 pts

When did the client's disability begin? * Date the client was no longer able to work due to their condition

Onset timing (auto)

Enter disability start date above 0 pts

Previous SSA application history

Application date (if already filed) Leave blank if not yet filed

7 Hearing Office & Judge (if at hearing stage)

0 / 5 pts ▾

Hearing office location (if assigned)

Judge's name (if assigned)

Judge's approval rate (if known) Enter as a whole number percent. Source: SSA OHO data at ssa.gov/appeals/DataSets/

Judge overlay (auto)

Enter approval rate above 0 pts

8 Case Eligibility Flags

No flags ▾

Check all that apply. Any "Yes" is an automatic decline regardless of score.

Client is currently earning above $1,620/month (and not legally blind)

Client has had NO medical treatment in the past 12 months

Client has NEVER had any imaging, labs, or diagnostic testing of any kind

Active substance use is the primary reason the client cannot work

SSDI coverage expired more than 3 years ago with no documented disability before that date

A prior attorney withdrew from this case for cause

Client refuses or is noncompliant with recommended medical treatment (without good reason)

9 Fee Estimate

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Estimated monthly benefit amount $ Check SSA.gov "my Social Security" for estimate. SSI max 2025: $967/mo

Estimated months from today to decision Initial review: 3–6 months. Hearing stage: 18–30 months

Fee cap override (optional) Leave blank to use current cap. Enter only for fee petition cases.

10 Intake Notes

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Additional notes / observations