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Name
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First
Last
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City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Email
*
Phone
*
Has your child suffered any of the following harms related to their use of social media?
Bullying
Unhealthy concerns with body image
Extreme anxiety
Severe depression
Self-harm
Sleep deprivation
Eating disorder
Drug or alcohol abuse
Suicidal thoughts
Others
Check what applies to you.
Has your child been seen by a physician or mental health professional in connection with any of these harms?
*
Select Your Option
Yes
No
Has your child been hospitalized overnight or received inpatient treatment in connection with any of these harms?
*
Select Your Option
Yes
No
Consent
By submitting this form, I am agreeable to receive response text messages in regards to my legal inquiry, which may be considered advertising material. I understand my consent to this is not necessary to obtain legal services from CaseyGerry. Msg & Data Rates May Apply.
Name
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