Did the harmed individual first use the social media platform before the age of 18 and after 2012? *

Yes

What is the harmed person's Date of Birth? *

Which conditions has the individual suffered? (please describe) *

Has the individual received medical or psychological treatment from a healthcare professional for these conditions? *

Yes

Are you filing the claim as an individual, parent, or legal guardian? *

Individual

Parent

Legal Guardian

Are you currently represented by another Law Firm? *

Yes

First Name *

Last Name *

Email *

Phone *

ZIP Code *

By checking this box, I agree to be contacted at the phone number and email I provided by [BRAND NAME], and by law firms or legal service providers it works with, about my potential claim. This may include calls, text messages, and emails, including messages sent using automated technology. I understand that consent is not a condition of any purchase or service, and that message and data rates may apply. Message frequency varies. Reply STOP to opt out or HELP for help. I confirm that the information I've provided is accurate, that I am the individual, parent, or legal guardian filing on behalf of the harmed person, and that I agree to the [Privacy Policy] and [Terms of Service].