Free Case Evaluation

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Name*

Who is filling out this form?*

Select OneMyselfParent or legal guardian on behalf of my child

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Phone*

Which social media platform did your child primarily use?*

Select OneInstagram after 2011Facebook after 2007Snapchat after 2012TikTok after 2019YouTube after 2006Other social media platformsDidn't Use Social Media

When did your child start using social media?*

Select OneStarted before turning 18Started after turning 18

What is your child's current age?*

Select One17 or younger18-2425-older

How many hours per day did your child use social media?*

Select One1 hour2 hours3 hours4 hours5 hours6 hours7 hours or more

Do you believe social media caused your child to experience any of the following?*

Select OneSuicide Attempt or completedSuicide IdeationBody DysmorphiaSexual ExploitationSelf harmSexual AbuseEating DisorderDepressionAnxietyAnorexiaBulimiaDrug overdoseAccidental deathOther Diagnosis

Did your child receive treatment or a diagnosis related to any of the conditions above? If so, what kind?*

Select OneHospitalizedSaw a doctor or a specialistEmergency RoomCounselingOther treatmentNo treatment

What is your state of residence?*

Select OneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Are you currently working with an attorney regarding your child's case?*

Select OneYesNo

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