DTR Questionnaire

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Questionnaire

To get started please completely fill out the following assessment questionnaire.
All information collected will always remain confidential.

Claimant name and contact are required to submit.

Claimant Information (Person with the Disability)

Full Name

Birthdate

Address

Primary Phone

Secondary Phone

Confirm Email

Preferred Contact Time

Preferred Contact Method

How did you hear about us?

Current marital status

Net Income

Source of Income

Have you claimed bankruptcy?

If you claimed bankruptcy, what year?

Information about the person claiming the disability amount

(If different than the Claimant)

Full Name

Relationship to claimant

Phone #

Disability Description

Please select all that apply

ADHD	Agoraphobia	Alzheimer's Disease
Amputation	ALS	Angina
Anorexia	Anorexia Nervosa	Anxiety
Arthritis	Asperger's Syndrome	Asthma
Ataxia	Attention Deficit	Autism
Auto-Immune Disorder	Bi-Polar Disorder	Bladder Disorder
Blindness	Borderline Personality Disorder	Bowel Disorder
Brain Injury	Bulimia	Celia Disease
Cerebral Palsy	Chemical Sensitivities	Chronic Inflammatory
Chronic Fatigue Syndrome	Chronic Pain Disorder	Colitis
Conduct Disorder	COPD	Coronary Artery Disease
Crohn's Disease	Cystic Fibrosis	Dementia
Depression	Developmentally Delayed	Diabetes
Difficulty Dressing	Difficulty Hearing	Difficulty Managing Bowel/Bladder
Difficulty Walking	Difficulty Feeding Oneself	Diverticulitis
Down's Syndrome	Dyslexia	Emphysema
Epilepsy	Fetal Alcohol Syndrome	Fibromyalgia
Generalized Anxiety Disorder	Glaucoma	Hearing Loss
Heart Attack	Heart Defect	Hepatitis
Herniated Discs	HIV	Huntington's Disease
Global Developmental Delay	Hypermobility Syndrome	Irritable Bowel Syndrome
Learning Disability	Lupus	Mental Illness
Multiple Personality Disorder	Multiple Sclerosis	Nerve Damage
Obsessive Compulsive Disorder	Osteoarthritis	Panic Disorder
Paralysis	Paraplegic	Parkinson's Disease
Post Traumatic Stress Disorder	Psychotic Episodes	Quadriplegic
Schizophrenia	Scoliosis	Sleeping Disorder
Social Anxiety Disorder	Speech Disorder	Stroke

If the disability is not listed above please enter it here

Do you receive life-sustaining therapy? (Insulin pump, dialysis, etc.)

List any therapies or medications used frequently

Additional information you feel should be added

The following agreements must be accepted to submit this questionnaire.

All the information I have provided in this questionnaire is accurate and truthful.

I Agree

Disability Tax Results has permission to contact me and follow up on the submitted questionnaire.

I Agree