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Home > Online Screening for Disability Benefits

Online Screening for Disability Benefits

To apply for free legal help with a Disability Benefits problem, please complete the form below.

If your problem is in some other area of the law, please use your browser’s back button to return to the prior page and make a different selection.

LARC will assess your application to determine whether there are legal services available to help with your problem. If a referral to another agency is appropriate, LARC will do so.

Thank you.

Be sure to check any notice of decision you have received for appeal deadline information. You should file an appeal before your deadline in order to preserve your rights. If you decide you do not want to pursue an appeal, you can always withdraw your request.

Your Email Address: :

Only provide an email address if you are the only person who has access to it.

First Name: : *

Please enter the name of the person applying for legal services.

Middle Name::

Last Name: : *

Date of Birth:: *

Street Address: :

Address Line 2: :

City::

Zip Code: :

Home Phone#::

Work Phone#: :

Cell Phone#: :

What is the best phone number for us to call?: : *

Home

Work

Cell

Is it safe for us to call at these numbers?:: *

Yes

No

Best time to reach you Monday-Friday between 9am and 4pm?: *

Please provide us several dates and times between 9am – 4pm, Monday – Friday , that you will be available for us to call you.

Is it safe for us to leave a message at these numbers?:: *

Yes

No

Please describe any special instructions or information concerning how to contact the person applying for services::

If you are submitting this application for another person, please tell us who you are and your relationship to the applicant: :

(family member, service provider, etc.)

Are you seeking or receiving disability benefits from :

the Social Security Administration (SSA)

NH Dept of Health & Human Services (HHS)

Both SSA and NH Dept of HHS

Have you filed an application? :

Yes

No

For what program(s) have you applied? (check all applicable):

Social Security Disability Insurance (SSDI) – from SSA

Supplemental Security Income (SSI) – from SSA

Aid to the Permanently and Totally Disabled (APTD) – from HHS

Have you received a decision?:

Yes

No

Were you denied?:

Yes

No

If so, for which program(s) were you denied?:

SSDI

SSI

APTD

What is the date of the denial?:

(If more than one, write in additional dates here::

Have you filed an appeal for each denial?:

Yes

No

Do you have a hearing scheduled?:

Yes

No

If so, what is your hearing date?:

If you have more than one hearing date, write in additional dates here::

Very briefly, what is the nature of your disability or disabilities?New component name:

Are you receiving medical or mental health treatment for those conditions?:

Yes

No

Date you were last employed?:

If you have not been denied disability benefits, briefly describe your legal problem here: :

The number of people who live with you under the age of 18, including yourself::

The number of people who live with you over the age of 18, including yourself: :

Total income before taxes of everyone who lives in your household: $ :

The income listed above is received: :

Weekly

Bi-weekly

Semi-monthly

Monthly

Please select from the list below how you heard about this application:

Attorney

Court

Credit Counselor

Crisis Center

Family

Friend

Housing agency or authority

Internet search

Low Income Taxpayer Clinic

Library or librarian

New Hampshire Legal Assistance

New Hampshire Bar Association

Other Legal Services Office

Pamphlet

Prior use

State Agency

Social Service Agency

The Way Home

Town Office

UNH Law School

211 NH

Other

Are you a U.S. Citizen?:

Yes

No

Non-citizens may still be eligible for services, but we might need more information about your status. No information we gather is shared outside of the legal services agencies without your permission.

Are you or is a member of your household a veteran?:

Yes

No

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Legal Advice & Referral Center	New Hampshire Legal Assistance
The Disabilities Rights Center	The Pro Bono Program of the New Hampshire Bar Association

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