Do you already have an attorney? Select an option No Yes
How will you finance legal services? Select an option Borrowing Personal savings Family support Current income Will discuss payment options with my attorney Cannot afford legal fees
Was there an accident or injury? Select an option No Yes
Do you want to challenge the DUI? Select an option No Yes
Do you want to challenge license suspension? Select an option No Yes
Do you have prior DUI offenses? Select an option No Yes
Any other tickets? Select an option No Yes
Court date
Do you need your license urgently? Select an option No Yes
Additional details
Do you already have an attorney? Select an option No Yes
What caused your injury? Select cause of injury Auto Accident Work Injury Slip & Fall Medical Malpractice Product Liability Animal Bite Assault Nursing Home Abuse Boating Accident Aviation Accident Other
Please specify cause of injury
What type of injury did you suffer? Select injury type Broken Bones Head Injury Back/Neck Injury Burns Internal Injuries Emotional Distress Spinal Cord Injury Paralysis Wrongful Death Other
Please specify injury type
When did the injury occur?
Estimated medical bills Select estimated amount Less than $10k $10k - $25k $25k - $50k $50k - $100k $100k - $250k $250k+
Was the accident your fault? Select an option No Yes
Describe your case
Do you already have an attorney? Select an option No Yes
How will you finance legal services? Select an option Borrowing Personal savings Family support Current income Will discuss payment options with my attorney Cannot afford legal fees
Reason for bankruptcy Select an option Garnishment Creditor Harassment Repossession Foreclosure Lawsuits Illness / Disability License Suspension Divorce Loss of Income Other
Total debt amount
Additional details
Do you already have an attorney? Select an option No Yes
How will you finance legal services? Select an option Borrowing Personal savings Family support Current income Will discuss payment options with my attorney Cannot afford legal fees
Current marital status Select an option Unmarried, Living Together Unmarried, Not Living Together Married, Living Together Separated Divorced Other
How soon do you want to hire an attorney? Select an option Immediately 1-3 months 3-6 months 6+ months
Has the case been filed in court? Select an option No Yes
Is a hearing scheduled? Select an option No Yes
Do you live with your spouse? Select an option No Yes
Status of issues Select an option Many outstanding issues Some outstanding issues Agreement reached
Your income
Spouse income
Shared assets Select an option House Vehicle(s) Vacation Property Jewelry Pension Stocks/Bonds IRA Other
Does your spouse have an attorney? Select an option No Yes
Number of children
Additional details
Do you already have an attorney? Select an option No Yes
Have charges been filed? Select an option No Yes
How will you finance legal services? Select an option Borrowing Personal savings Family support Current income Will discuss payment options with my attorney Cannot afford legal fees
Has anyone been arrested? Select an option No Yes
Is a court date scheduled? Select an option No Yes
Court date
Who is accused? Select an option Me Friend Parent Brother Sister Other Relative
Type of charge Select an option Drug Related Assault Property Crime Crime Against Children Sex Crime White Collar Traffic Ticket DUI Other
When did the incident occur? Select an option <1 month 1-3 months 4-6 months 7-12 months >12 months
Describe the charge
Do you already have an attorney? Select an option No Yes
Do you have a doctor? Select an option No Yes
Have you visited a doctor? Select an option No Yes
Outcome of doctor visit
Have you applied for disability? Select an option No Yes
Claim status Select an option No Initial Stage Under Reconsideration Administrative Law Judge Appeals Council
When did condition start? Select an option <1 year 1-3 years 3-5 years >5 years
Unable to work? Select an option No Yes
Age
Date of birth
Describe your disability
Receiving benefits? Select an option No Yes
Additional details
Do you already have a tax attorney? Select an option No Yes
Date of birth
Type of tax issue Select tax type Federal State Both
Is this business or personal tax? Select tax category Business Personal Both
Total tax debt amount Select debt range Less than $10k $10k - $20k $20k - $30k $30k - $40k $40k - $50k $50k - $60k $60k - $70k $70k - $80k $80k - $90k $90k - $100k More than $100k
Have you filed your tax returns? Select an option No Yes
What is your main tax problem? Select issue Wage Garnishment Unpaid Taxes Bank Levy Innocent Spouse IRS Levy Penalties Lien
Cancer type diagnosed Select cancer type Bladder Cancer Colon Cancer Esophageal Cancer Hodgkin's Lymphoma Kidney Cancer Lung Cancer Mesothelioma Multiple Myeloma Non-Hodgkin's Lymphoma Laryngeal Cancer Rectal Cancer Stomach Cancer Throat Cancer Leukemia Other
Year diagnosed
Have you consulted an attorney? Select an option No Yes
Additional details
Injuries experienced Select an option Gynecomastia Galactorrhea Breast growth Swollen nipples
Age
Date medication started
Medication type Select an option Risperdal Oral Risperidone Oral Risperdal Consta Paliperidone Generic Risperdal Not Sure
Have you consulted an attorney? Select an option No Yes
Additional details
Complications experienced Select an option Non-removable Tilted Fracture Migration Perforation Embolization Punctured organs Death Other
IVC filter brand Select an option Bard Cook Greenfield Johnson & Johnson Don't know Other
Implanted after 2003? Select an option No Yes
Have you consulted an attorney? Select an option No Yes
Additional details
Side effects experienced Select an option Internal bleeding Rectal bleeding Hemorrhagic stroke Death Ischemic stroke DVT Pulmonary embolism Other clots Heart attack
Hospitalized 24+ hours? Select an option No Yes
Occurred after Jan 2012? Select an option No Yes
Doctor told to stop? Select an option No Yes
Have you consulted an attorney? Select an option No Yes
Diagnosed with ovarian cancer in last 10 years? Select an option No Yes
Used talcum powder for 4+ years? Select an option No Yes
Are you over 65? Select an option No Yes
Did loved one pass away in last 3 years? Select an option No Yes
Are you BRCA negative? Select an option No Yes
Have you consulted an attorney? Select an option No Yes
Had bladder sling or TVM surgery? Select an option No Yes
Surgery in 2005 or after? Select an option No Yes
Reason for surgery Select an option Stress Urinary Incontinence Pelvic Organ Prolapse Other
Surgery performed vaginally? Select an option No Yes
Revision surgery done? Select an option No Yes
Revision surgery after 2005? Select an option No Yes
Revision performed vaginally? Select an option No Yes
Revision under anesthesia? Select an option No Yes
Have you consulted an attorney? Select an option No Yes
Additional details
Have you consulted an attorney? Select an option No Yes
Type of injury Select an option ALS Aplastic anemia Birth defects Bladder cancer Brain cancer Breast cancer Cardiac birth defects CNS cancer Cervical cancer Colorectal cancer Esophageal cancer Female infertility Fetal death Fatty liver disease Hodgkin's lymphoma Kidney cancer Kidney disease Leukemia Liver cancer Lung cancer MDS Miscarriage Multiple myeloma Neural tube defects No injury Non-Hodgkin's lymphoma Other cancer Other injury Pancreatic cancer Parkinson's disease Prostate cancer Rectal cancer Renal toxicity Scleroderma Soft tissue sarcoma Thyroid cancer
Years at Camp Lejeune Select an option 1953-1987 After 1987 Before 1953 Never lived there Less than 30 days
Relationship type Select an option Child contractor Child service member Civilian employee Military contractor Service member Other contractor relation Other service relation Spouse contractor Spouse service member
Additional details
Have you consulted an attorney? Select an option No Yes
Year of diagnosis Select an option 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Before 2012 Not diagnosed
Used hair straightener? Select an option No Yes
Type of injury Select an option Breast cancer Endometrial cancer Fibroids Hair loss Infertility None Other cancer Other injury Ovarian cancer Uterine cancer
Type of cancer Select an option T-ALCL B-Cell Burkitt CLL DLBCL Follicular Hairy Cell Mantle Mycosis Fungoides No Cancer NHL Other Cancer Other NHL Plasmacytoma CNS Lymphoma Sezary SLL T-Cell
Exposure type Select an option Not exposed Direct Indirect
Exposure duration Select an option 1 year 2+ years <1 year None
Exposed to Paraquat? Select an option No Yes
Herbicide used Select an option Paraquat Ortho Gramoxone Firestorm Helmquat Parazone Concentrate Blanco Cyclone Bonedry Devour Para shot None
Agricultural worker? Select an option No Yes
Applied Paraquat personally? Select an option No Yes
Diagnosed with Parkinson’s? Select an option No Yes
Symptoms Select an option Balance Bradykinesia Reduced motion Speech issues Swallowing issues Drooling Micrographia Paralysis Facial reduction Rigidity Sleep issues Spasms Tremors None
PD medications Select an option Amantadine Apokyn Artane Axilect Cogentine Elepryl Kynmobi Sinemet Mirapex Neupro Nourizanz Requip Xadago Zelapar Other
Age at diagnosis Select an option <21 21-34 35-54 55-74 75+
Have you consulted an attorney? Select an option No Yes
Cancer type Select an option Kidney Testicular Prostate Liver Pancreatic Thyroid Bladder Leukemia NHL Ulcerative colitis
Diagnosis date
Diagnosed in last 4 years? Select an option No Yes
Used PFAS products 12+ months? Select an option No Yes
Has attorney? Select an option No Yes
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