Referral Form Instructions

Please complete the following form for the individual you are referring.

* First, provide the contact information for the person you are referring.

* Next, enter your own contact information or that of someone else we can contact about them.

* The remaining questions relate to the referred individual to help us evaluate how we may be able to assist.

If you have any questions while completing the form, please don’t hesitate to contact us at (808) 536-8074 or by email at team@hawaiidisabilitylegal.com

Contact information: Contact 1

Prefix

First name *

Middle name

Last name *

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Contact information: Someone Else We Can Contact (i.e. a Case Manager)

Prefix

First name *

Middle name

Last name *

Emails

Email Address *

Type

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

Contact information: Contact 1

Contact information: Someone Else We Can Contact (i.e. a Case Manager)

Date of Birth

Does this person need help with a new Social Security application or help with a recent denial?

If this person already has a Social Security claim, do they already have a lawyer who is helping them?

Is this person currently employed?

What are the medical conditions that limit this person's physical and/or mental abilities to do work?

Is this person currently receiving general assistance?

Is this person married?

Is there any information you would like to add about this person or their disability? Please add it here.

Please attach any documents here that you would like us to consider.