What is your relation to the individual that played the video games? *

Myself

Loved one

Is Injured Party currently going to school? *

Yes

No

Is the person who played video games a minor (under age of 18)? *

Yes

No

Highest Level of Education for Gamer? *

Gender *

Estimate the date that injured party first started playing video games? *

On Average how many hours per day gaming? *

0-1

2-3

3+

Gamertag / PSN ID *

Select All Gaming Platforms That Have Been Used. *

Playstation

Xbox

Nintendo Switch

Gaming Computer or Laptop

Steam

Apple iPhone

Android Phone

Oculus VR

Meta Quest

Other Gaming Device

Select all video games that have been played. *

Apex Legends

Call of Duty

Counter-Strike

Fortnite

GTA 5

League of Legends

Minecraft

Overwatch

Rainbow Six: Seige

Roblox

Teamfight Tactics

Valorant

World of Warcraft

Other Game

What video game that was played first? *

Please list the game names including the version, dates, and estimated hours spent playing each of the above game. (Optional)

Do you subscribe to any cloud/internet gaming subscription(s) (online gaming subscriptions) *

Yes

No

Unsure

Which monthly subscription(s) did you purchase? *

Game Pass Ultimate

Game Pass Core

Xbox Live Gold

Playstation Premium

Playstation Extra

Playstation Essential

EA Play

EA Play Pro

Apple Arcade

Google Play Pass

Amazon Prime Gaming

NVIDIA GeForce NOW

Amazon Luna

Roblox Premium

Ubisoft Classics

Ubisoft Premium

Fortnite Battlepass

Fortnite Crew Subscription

Other Subscription

No Monthly Subscription

Do you have photos, witnesses, or any proof that video games were played/used? *

Photos

Witnesses

Other Proof

On average how much money per month was spent on video gaming? *

Do you have receipts for any video games related purchased? *

Yes

No

Do you use virtual reality headsets, gloves, or other video game accessories? *

Yes

No

Have you tried to stop or give up gaming? *

Yes

No

Have you ever watched social media gaming influencers on YouTube. TikTok, or any other websites? *

Yes

No

Did you pay for additional items in the video games, such as loot, level up options, rewards, badges, or additional game content? *

Yes

No

Unsure

Did you sell in video game content or loot (level, persons, badges,etc.) for money *

Yes

No

Did you receive a reward of an energy drink or powder with Battle Pass or other video games? *

Yes

No

Do not know

Select all internet gaming disorder symptoms that the individual has experienced or has been witnessed since playing video games *

Have you had any of the following injuries or diagnoses due to video games? *

Have video games affected your life in any of the following ways?* *

Drop in grades

Dropout of school

Hiding or lying about game playing time

Inability to stop playing games

Poor Hygiene due to excessive video gaming

Received an individualized Education Plan (IEP)

Social isolation

Stealing money for gaming

Withdrawal symptoms

Other Affects

No affects from video games

Have you received any of the following medical treatments due to playing video games? *

Counseling

Doctor visits

Hospitalization

In person gaming addiction program

Online gaming addiction program

Therapy

Other treatment

No treatment

Did a medical provider diagnosis and/ or treat you for any of the gaming related injuries? *

Yes

No

Was any medication taken to treat you for any of the gaming related injuries? *

Yes

No

List any other medical conditions you have been diagnosed with in the past ten years? *

Have you previously signed documents with an attorney for this claim? *

Yes

No

Have you filed a lawsuit or been a defendant in a lawsuit? *

Yes

No

Have you ever been convicted of a misdemeanor or felony? *

Yes

No

Do you receive SSDI (Social Security Disability Insurance) benefits? *

Yes

No

Do you receive SSI (Supplemental Security Income) benefits? *

Yes

No

Emergency Contact Name *

Emergency Contact Phone # *

Emergency Contact Relationship to client *

Legal Full Name of person signing *

Full Name *

Email *

Phone *

Address *

Street Address

City

State

Country

Country

Postal code

Date of birth *

Social Security Number *

Upload Drivers License *

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