Alliant Disability - Client Intake Screening

1

Client Information

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Full Legal Name *

Date of Birth *

Social Security NumberStore securely — required for SSA filing

Age (auto)

Enter date of birth

Benefit Type (auto)

Enter work history in Section 4 below

Phone

Email

Street Address

City

State

ZIP Code

2

Medical Conditions

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Search Diagnoses (Blue Book)

Select from Blue Book above or type any diagnosis and click + Add

Primary Condition Category *

Suggested Tier (auto)

Select category above0 pts

Override Tier

Number of Conditions *

Both physical AND mental health?

🚩 Substance use is the PRIMARY cause of disability (mandatory decline)

3

Medical Records & Treatment

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Type of Medical Testing *Single strongest predictor of a favorable outcome

Length of Consistent Treatment *

Total Providers (past 2 years) *Count all seen at least twice

Of Those, Specialists? *Neurologist, cardiologist, psychiatrist, etc.

Provider Strength (auto)

Enter provider counts above0 pts

🚩 No medical treatment in past 12 months (mandatory decline)

🚩 Refuses recommended treatment (mandatory decline)

4

Work History & Background

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Current Work Status *

Earnings Status (auto)

Select work status0 pts

🚩 Confirmed earning at or above $1,620/month (mandatory decline)

Last Day Worked / Date Disability Prevented WorkMay differ from onset date - use the last actual day at work

Worked 5 out of the last 10 years? *Required for SSDI eligibility - determines insured status

Total assets over $2,000? (cash, savings, property)SSI asset limit is $2,000 individual / $3,000 couple

Most Recent Job (last 5 years)

Selecting a job auto-fills skill level and suggests current RFC — ask the client about physical demands and select below

Physical Demands of That Job * (what they did — not what they can do now)

Vocational Profile (auto)

Select RFC and past job above0 pts

Highest Education *

English Proficiency

5

Physical Ability & Limitations

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RFC Helper - Ask these questions first, then select the RFC level below.

Max continuous sitting (best day)Sedentary = can sit most of an 8-hr day

Max continuous standing/walking (best day)Light = up to 6 hrs · Sedentary = up to 2 hrs

Max weight able to lift/carry

RFC Suggestion (auto)

Answer sit/walk/lift above

Most Physical Work Client Can Do Now * (current RFC — drives vocational score)Override auto-suggestion if clinical detail warrants it

⚠ This overrides the suggested RFC — make sure clinical notes support it

Additional Limitations Beyond Physical?

6

Application Timeline

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Last Date Insured for SSDI (SSDI only)Leave blank for SSI-only

Insurance Status (auto)

Select benefit type first0 pts

🚩 SSDI coverage expired 3+ years ago with no qualifying onset (mandatory decline)

When Did Disability Begin? *Date client was no longer able to work

Onset Timing (auto)

Enter disability start date0 pts

Prior Application History

Application Date (if filed)

7

Fee Estimate

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Est. Monthly Benefit ($) auto-estimated · override below

Enter benefit type above

SSDI avg 2025: $1,537/mo · Concurrent (SSDI+SSI): SSDI + gap fill

Est. Months to Decision auto-estimated · override below

Enter prior app history above

Based on claim stage · ALJ hearing avg 28 months

Fee Cap Override

8

Intake Notes

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Notes / Observations