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Welcome to the Yocum, Krowl & Associates Client Intake

This secure form helps us understand your background, work history, and medical conditions so we can evaluate your Social Security Disability matter. It usually takes 5–10 minutes. You can save and return anytime when using your client portal login.

Client Intake Form

If you need help with this form, call us at 812-421-1865 or email brandy@yocumlaw.com.

If this is an emergency or you are facing an immediate deadline from SSA, contact our office directly after submitting this form.

What You’ll Need

Basic contact information (phone, email, mailing address)
Work history (last date worked, recent employment)
Medical conditions/diagnoses and treating providers (if known)
Benefit and claim status (whether you’ve already filed, have a representative, etc.)
Any deadlines or upcoming SSA appointments or hearings

How We Use Your Answers

To confirm whether we can assist you and to identify next steps
To check for potential conflicts of interest
To prepare for your consultation and streamline document requests

Tips for Completing the Form

Be specific about conditions and dates (approximate is okay if you’re unsure).
If a question doesn’t apply, choose N/A or leave it blank (unless required).
Uploads: PDFs or clear photos/scans of letters from SSA, medical records, and pay stubs can be helpful.
If you lose your connection, you can resume via your portal—your progress is saved when logged in.

This field is for validation purposes and should be left unchanged.

Name(Required)

First Middle Last

Date of Birth

MM slash DD slash YYYY

Phone

Email(Required)

Mailing Address

Street Address Address Line 2 City State ZIP Code

Are you currently working?

Yes

When was the last time you worked?

Would you say you have worked 5 out of the last 10 years?

Yes

Do you owe any back taxes or child support?

Yes

Do you have current representation for a Social Security Disability Claim?

Yes

Have you started a claim yet?

Yes

What are your conditions, illnesses, and/or injuries? What prevents you from working?

Terms of Use Consent

No attorney-client relationship(Required)

I acknowledge that submitting this intake does not create an attorney-client relationship.

Consent to review/processing (incl. health info)(Required)

I consent to Yocum, Krowl & Associates using my information—including health information—for conflicts checks and to evaluate my potential case.

Accuracy attestation(Required)

I affirm the information I’m providing is true and complete to the best of my knowledge.

Communications consent(Required)

I consent to receive communications about my intake via email, phone, SMS/text, and portal messages.

Engagement agreement reminder(Required)

I understand representation only begins after both I and the firm sign an engagement agreement.

Uploads of medical/SSA records

I authorize the firm to review any medical records or SSA documents I upload through this portal for the limited purpose of evaluating my claim.

Terms & Privacy(Required)

I agree to the firm’s Terms of Use and Privacy Policy.

File

Max. file size: 60 MB.

CAPTCHA

Disclaimers & Terms of Use

1) No Attorney-Client Relationship Yet – Submitting this form does not create an attorney-client relationship with Yocum, Krowl & Associates. We can only represent you after we complete a conflict check and both you and the firm sign an engagement agreement.

2) Accuracy of Information – You confirm that the information you provide is true and complete to the best of your knowledge. If you need to correct anything, you may update your intake in the portal or notify us promptly.

3) Confidentiality & Privacy – Information you submit is treated as confidential. We use industry-standard security measures and our client portal to protect your data. Please avoid emailing sensitive documents unless specifically requested—use the portal whenever possible.

4) Health Information Notice – This intake may include health/medical information. By submitting, you consent to our limited use of this information to evaluate your matter and determine next steps. A separate written authorization (HIPAA release) may be required before we request medical records.

5) Electronic Communications – You agree we may contact you via email, phone, SMS, and portal messages at the contact information you provide. Message/data rates may apply. You can update your preferences in the portal or by contacting our office.

6) Conflicts Check – Your information will be used for a conflicts check. If a conflict exists, we will notify you and, when appropriate, refer you elsewhere.

7) Jurisdiction & Deadlines – Our attorneys are licensed in specific jurisdictions. Filing deadlines may apply to your claim; completing this form does not guarantee that we will act on any deadline unless and until you have signed an engagement agreement and we confirm representation in writing.

8) No Legal Advice – The intake form and any automated responses are general information, not legal advice. Legal advice is provided only after retention under an engagement agreement.

9) Document Handling & Retention – Uploaded documents are stored securely in your portal. We retain intake records consistent with our firm’s record retention policy. You may request copies through the portal.