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Main Gaming Intake Form

PLEASE READ BEFORE CONTINUING
Thank you for choosing Bullock Legal Group to represent you and evaluate your video game addiction claims.

In order for us to investigate your claims and determine if you have a viable action against the video game companies, it is vital that you FULLY complete this intake form and provide us with detailed information about the gamer’s video game usage as soon as possible. Please note, this intake form is separate from the initial short questionnaire that you filled out when you signed up with our firm.

We understand that this intake form may take some time to fully complete, however, we promise that every question in this form is vital to determining if you have a viable action against the video game companies.

If you need to collect additional information to fully complete this intake form, you can click the SAVE button at the bottom of the screen and create an account. You will receive an email from [email protected] with a link to continue filling out the form when you are ready.

If you do not fully complete this form or fail to provide detailed information, then we will be UNABLE to investigate and evaluate your case.

Part 1: Personal Information
Are you the video game player or are you the parent/guardian of the video game player?*

I am the video game playerI am the parent/guardian of the video game playerOther

Are you over the age of 18?*

YesNo

Parent or Guardian's Information
Please provide your contact information:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
[email protected]
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
What is Your Relationship to the Gamer?*

FatherMotherLegal Guardian
What is your Current Marital Status?*

Never MarriedMarriedDivorcedWidow/WidowerOther
What type of custody do you have of your child?*

Mother Sole CustodyFather Sole CustodyJoint Legal CustodyGuardianshipOther

Parent or Guardian's Information
Please enter the contact information of the other parent or guardian's contact information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address*
[email protected]
Is the other parent or guardian's Physical Address the same as yours?*

YesNo
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code

Parent or Guardian's Information
Do you or the other parent play video games with your child?*

YesNo
Do you or the other parent play on a separate gaming account than your child?*

YesNo

Please provide your separate gaming account information:
Please provide your separate gaming account information:
Account Name or Gamer Tag*
‎
Email Address Associated with Your Account*
[email protected]
Second Account Name or Gamer Tag
‎
Email Address Associated with Your Second Account
[email protected]

Gamer's Information
Please Provide the Gamer's Contact Information
Name*

First NameLast Name
Gamer's Date of Birth*

MonthDayYear
TODAYS DATE

MonthDayYear

Date
Age - days
Based on your response the gamer's age is:
Phone Number*
Please enter a valid phone number.
Email Address*
[email protected]
Is the Gamer's Physical Address the same as yours?*

YesNo
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code

Part 2: Video Game Information
Gaming History
What age did the Gamer start playing video games?*
How many hours a day during the week does the gamer play videos games?*
How many hours a day on the weekends does the gamer play video games?*

Gaming Console Information
Select the gaming consoles and/or phones the gamer plays or has played videos games on:*

XboxVirtual Reality Gaming ConsolesPlaystationApple iPhoneNintendo SwitchGoogle AndroidComputerOther

Xbox related questions
Xbox Gaming Questions
1. What Xbox gaming consoles has the gamer played on?
2. What is the gamer's Xbox Gamertag and email address associated with the gamers Xbox account?
In order for us to evaluate your claims, it is extremely important that you provide ALL of the gamer's gamertags.

Here are some ways you can lookup the gamer's gamertag, if you do not know them:

Xbox Console:

Watch this step-by-step YouTube video: https://www.youtube.com/watch?v=8Cu_dAzRmUU&t=21s
1. Turn on your Xbox console and sign in to your profile.
2. Press the Xbox button on your controller to open the guide.
3. Go to "Profile & system" by navigating left (icon with your profile picture).
4. Select "My profile". Your gamertag will be displayed at the top of the screen.
5. To find your email address, select "Settings" from the "Profile & system" menu.
6. Navigate to "Account" > "Sign-in, security & passkey". Your email address will be displayed under "Show on Home."
Xbox Mobile App
1. Open the Xbox mobile app and sign in to your account.
2. Tap on your profile icon in the bottom-right corner of the screen.
3. Your gamertag will be displayed at the top of the screen.
4. To find your email address, tap on "Settings" (gear icon).
5. Tap on "Account", and your email address will be shown.
Xbox.com
1. Go to Xbox.com and sign in to your account.
2. Click on your profile picture in the top-right corner.
3. Select "Xbox profile" from the dropdown menu. Your gamertag will be displayed at the top.
4. To find your email address, click on "Account" (next to your profile picture).
5. Select "Your info". Your email address will be displayed on this page.
Xbox Gamertag*
Account Email Address*
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Second Xbox Gamertag
Second Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Third Xbox Gamertag
Third Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account

PlayStation related questions
PlayStation Gaming Questions
1. What PlayStation gaming consoles has the gamer played on?
2. What is the gamer's PSN ID and email address associated with the gamers Playstation account?
In order for us to evaluate your claims, it is extremely important that you provide ALL of the gamer's PSN ID’s and Email Addresses.

Here are some ways you can lookup the gamer's PSN ID’s and Email Addresses, if you do not know them:

PlayStation Console

Watch the step-by-step YouTube Video: https://www.youtube.com/watch?v=s_b9Ulg7plc
1. Turn on your PlayStation console and sign in to your profile.
2. Press the PS button on your controller to open the control center.
3. Navigate to your profile by selecting your profile picture or icon.
4. Select "Profile". Your PSN ID (gamertag) will be displayed at the top of the screen.
5. To find your email address, go to "Settings" from the main menu.
6. Navigate to "Account Management" > "Account Information" > "Sign-In ID (Email Address)". Your email address will be displayed here.
PlayStation Mobile App
1. Open the PlayStation App and sign in to your account.
2. Tap on your profile icon in the bottom-right corner of the screen.
3. Your PSN ID (gamertag) will be displayed at the top of the screen.
4. To find your email address, tap on "Settings" (gear icon).
5. Tap on "Account Information", and your email address will be shown.
PlayStation.com
1. Go to PlayStation.com and sign in to your account.
2. Click on your profile picture in the top-right corner.
3. Select "Account Settings" from the dropdown menu. Your PSN ID (gamertag) will be displayed here.
4. To find your email address, go to "Security". Your email address will be displayed under "Sign-In ID."
PSN ID Playstation*
Account Email Address*
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Second PSN ID Playstation
Second Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Third PSN ID Playstation
Third Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account

Nintendo Switch related questions
Nintendo Gaming Questions
1. What is the gamer's Nintendo Switch username and the email address associated with the Gamer's Nintendo account?
In order for us to evaluate your claims, it is extremely important that you provide ALL of the gamer's Nintendo Account nicknames and Email Addresses.

Here are some ways you can lookup the gamer's Nintendo Account nicknames and Email Addresses, if you do not know them:

Nintendo Switch Console

Watch the Step-by-Step YouTube Video: https://www.youtube.com/watch?v=gHB8QFkw13M
1. Turn on your Nintendo Switch console and sign in to your profile.
2. Go to the Home Menu and select your profile icon in the top-left corner.
3. Your Nintendo Account nickname (similar to a gamertag) will be displayed at the top of the screen.
4. To find your email address, select "User Settings" from your profile page.
5. Navigate to "Link Nintendo Account". If your account is already linked, your email address will be displayed under "Linked Account."
Nintendo Switch Online Mobile App
1. Open the Nintendo Switch Online app and sign in to your account.
2. Tap on your profile icon in the top-right corner of the screen.
3. Your Nintendo Account nickname will be displayed at the top of the screen.
4. To find your email address, tap on "Account Information" under your profile.
5. Your email address will be shown on the Account Information page.
Nintendo.com
1. Go to Nintendo.com and sign in to your account.
2. Click on your profile picture in the top-right corner.
3. Select "Account Settings" from the dropdown menu. Your Nintendo Account nickname will be displayed here.
4. To find your email address, go to "User Info" under "Account Settings". Your email address will be displayed under "Email Address".
Nintendo Username*
Account Email Address*
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Second Nintendo Username
Second Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Third Nintendo Username
Third Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account

Virtual Reality related questions
Virtual Reality Gaming Questions
1. What Virtual Reality gaming consoles has the gamer played on?
In order for us to evaluate your claims, it is extremely important that you provide ALL of the gamer's Oculus Usernames and Email Addresses.

Here are some ways you can lookup the gamer's Oculus Usernames and Email Addresses, if you do not know them:

Watch the step-by-step YouTube video: https://www.youtube.com/watch?v=vC4GgsMdyyA

Oculus VR Headset
1. Turn on your Oculus VR headset and put it on.
2. Press the Oculus button on the right controller to open the Universal Menu.
3. Navigate to your profile by selecting your profile picture or icon in the top-right corner.
4. Your Oculus username will be displayed at the top of your profile page.
5. To find your email address, go to "Settings" from the Universal Menu.
6. Navigate to "Account". Your email address will be displayed here.
Oculus Mobile App
1. Open the Oculus app and sign in to your account.
2. Tap on your profile icon in the bottom-right corner of the screen.
3. Your Oculus username will be displayed at the top of the screen.
4. To find your email address, tap on "Settings" (gear icon).
5. Tap on "Account Settings". Your email address will be shown under "Email Address".
Oculus.com
1. Go to Meta.com and sign in to your account.
2. Click on your profile picture in the top-right corner.
3. Select "My Profile" from the dropdown menu. Your Oculus username will be displayed here.
4. To find your email address, go to "Account Settings". Your email address will be displayed under "Email".
2. What is the gamer's Virtual Reality username and email address associated with the gamer's Virtual Reality account?
Virtual Reality Username*
Account Email Address*
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Second Virtual Reality Username
Second Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account

Apple iPhone related questions
Apple iPhone Phone Gaming Questions
1. What is the Gamer's email address associated with the their Apple iPhone?
In order for us to evaluate your claims, it is extremely important that you provide ALL of the gamer's Apple iPhone’s Email Addresses.

Here are some ways you can lookup the gamer's Apple iPhone’s Email Addresses, if you do not know them:

On iPhone
1. Open the Settings app on your iPhone.
2. Tap on your name at the top of the Settings menu. This will take you to your Apple ID profile.
3. Your Apple ID (email address) will be displayed under your name at the top of the screen.
4. To view more details, you can tap on "Name, Phone Numbers, Email". Your Apple ID and other associated email addresses will be shown on this page.
Online (Apple ID Website)
1. Go to appleid.apple.com in your web browser.
2. Sign in with your Apple ID and password.
3. After signing in, you will see your Apple ID (email address) displayed at the top of the Account section.
4. To view or edit your email address, click on "Edit" in the Account section. This will show you all the email addresses associated with your Apple ID.
Apple Account Email Address*
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Second Apple Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account

Andriod related questions
Android Phone (Google Play) Gaming Questions
1. What is the Gamer's email address associated with the their Android (Google Play) Phone?
In order for us to evaluate your claims, it is extremely important that you provide ALL of the gamer's Android Phone’s Email Addresses.

Here are some ways you can lookup the gamer's Android Phone’s Email Addresses, if you do not know them:

On Android Phone (Google Play)
1. Open the Google Play Store app on your Android phone.
2. Tap on your profile icon in the top-right corner of the screen.
3. Your Google account email address will be displayed under your name at the top of the menu.
4. To view more details, tap on "Manage your Google Account". This will open your Google Account settings.
5. Navigate to the "Personal info" tab. Here you can see and manage your email addresses associated with your Google account.
Online (Google Account Website)
1. Go to myaccount.google.com in your web browser.
2. Sign in with your Google account email and password.
3. After signing in, you will see your Google account email address displayed at the top of the page.
4. To view or edit your email address, click on "Personal info" in the left sidebar. Here you can see and manage your email addresses associated with your Google account.
Android Account Email Address*
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Second Android Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account

Computer related questions
Computer Gaming Questions
1. What is the Gamer's email address associated with the their Computer Gaming?
Computer Account Email Address*
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Second Computer Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account
Third Account Email Address
Who created this account?*

I created this accountMy child created this account
Were you aware that your child created this account?*

I was not aware that my child created this accountI was aware my child created this account

Gaming Subscriptions

XBOX related questions
Since you or the gamer plays on the Xbox, which monthly subscription did you purchase?*

Game Pass UltimateGame Pass CoreXbox Live GoldNone of these
Game Pass Ultimate*
Subscription Start Year
‎
Subscription End Year
Game Pass Core*
Subscription Start Year
‎
Subscription End Year
Xbox Live Gold*
Subscription Start Year
‎
Subscription End Year

PlayStation related questions
Since you or the gamer plays on the PlayStation, which monthly subscription did you purchase?*

Playstation PremiumPlaystation ExtraPlaystation EssentialNone of these
PlayStation Premium*
Subscription Start Year
‎
Subscription End Year
PlayStation Essential*
Subscription Start Year
‎
Subscription End Year
PlayStation Extra*
Subscription Start Year
‎
Subscription End Year

Game Specific Subscriptions
Have you or the gamer ever subscribed to any of the following gaming subscription?*

Call of Duty Game PassFortnite Battle PassRoblox PremiumEA PlayEA Play ProApple ArcadeGoogle Play PassAmazon Prime GamingNVIDIA GeForce NOWAmazon LunaUbisoft ClassicsUbisoft PremiumFortnite Crew SubscriptionNone of the Above
EA Play*
Subscription Start Year
‎
Subscription End Year
EA Play Pro*
Subscription Start Year
‎
Subscription End Year
Apple Arcade*
Subscription Start Year
‎
Subscription End Year
Google Play Pass*
Subscription Start Year
‎
Subscription End Year
Amazon Prime Gaming*
Subscription Start Year
‎
Subscription End Year
NVIDIA GeForce Now*
Subscription Start Year
‎
Subscription End Year
Amazon Luna*
Subscription Start Year
‎
Subscription End Year
Roblox Premium*
Subscription Start Year
‎
Subscription End Year
Ubisoft Premium*
Subscription Start Year
‎
Subscription End Year
Ubisoft Classic*
Subscription Start Year
‎
Subscription End Year
Fortnite BattlePass*
Subscription Start Year
‎
Subscription End Year
Call of Duty Game Pass*
Subscription Start Year
‎
Subscription End Year
Fortnite Crew Subscription*
Subscription Start Year
‎
Subscription End Year

Proof of Gaming Subscriptions
Do you have any proof for the subscriptions purchases? Proof can be in the form of documents, photos, screenshots, or videos?*

YesNo
Please upload the photos, screenshots, videos, or documents of the subscription purchases?

Cancelof

Video Games
Select the videos games the Gamer plays or has played:
Most Played Games

Call of Duty Series
Call of Duty Series (By Year)

Please pay attention to the release date and pictures as many of the games have similar names
Since you selected the Call of Duty Series in the previous response, please select the specific Call of Duty Series that the Gamer has played.

Other Games Selection
Other Games

Gaming History
For each game you selected, please enter the year the gamer started and stopped playing and the hours the gamer played per week. This can be an estimate.

Gaming Transactions
If the Gamer has any spent money on the game, such as loot, level up options, rewards, badges, additional game content, etc, please enter the amount the gamer has spent and how the gamer paid for the purchases. This can be an estimate.

Gaming Proof of Purchase
Do you have any proof of the gaming purchases? Proof can be in the form of documents, photos, screenshots, or videos?*

YesNo
Please upload the photos, screenshots, videos, or documents of the gamering purchases?

Cancelof

Gaming Content
Has your child concealed or tried to conceal purchases of video games or content?*

YesNo
Please state how the child has tried to conceal purchase of the video games or content

Gaming Rewards
Has the Gamer ever received gaming rewards or points from energy drinks, snacks, or other non-gaming product? Examples include, Monster Energy Drinks, Rockstar Energy Drinks, Mountain Dew, Doritos, PepsiCo Products, Movie Tickets,Totinos, and Kroger Points Rewards,*

YesNo
Please specify the non-gaming products that the Gamer has received gaming rewards or points from:*

Part 3: Video Game Related Injuries
Has the Gamer experienced any of the following symptoms that have lasted more than 12 months:*

Diminished Social Interaction with FamilyLoss or Lack of Friends at SchoolDrop in GradesLack of Interest in other sports/hobbiesInability to limit game playing timePoor Hygiene due to game playing timeChange in eating pattern due to game playing timeGamer's Rage-losing or withdrawal of game prompts anger-throwing objects, punches walls/doors, yells, cursingNone of the above
Has the Gamer been diagnosed or experienced any of the following injuries:
Most Common Injuries

DepressionAnxietyCollege DropoutADHD/ADDSuicide AttemptOppositional Defiant DisorderHigh School DropoutVideo Gaming AddictionInternet Gaming Disorder
Other Injuries

Gamer's ThumbCarpal Tunnel SyndromeComputer Vision SyndromeTrigger FingerTennis ElbowSeizuresDe Quervains' TenosynovitisNeck Sprain/HerniationChanges in CT/MRI BrainSleep Deprivation PsychosisOther

Med Provider 1
Please provide the contact information of the medical provider who diagnosed the Gamer for their gaming-related injuries and the date of diagnosis:
Medical Provider Name*
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Date of Diagnosis*

MonthDayYear
Did this medical provider treat the Gamer with medication for their gaming-related injury?*

YesNo

Injury Medication 1
Please provide the name of the medication(s):*
‎
Was the Gamer treated by another medical provider for their gaming-related injury?*

YesNo

Med Provider 2
Please provide the contact information of the second medical provider who diagnosed the Gamer for their gaming-related injuries and the date of diagnosis:
Medical Provider Name*
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Date of Diagnosis*

MonthDayYear
Did this medical provider treat the Gamer with medication for their gaming-related injury?*

YesNo

Injury Medication 2
Please provide the name of the medication(s):*
‎
Was the Gamer treated by another medical provider for their gaming-related injury?*

YesNo

Med Provider 3
Please provide the contact information of the third medical provider who diagnosed the Gamer for their gaming-related injuries and the date of diagnosis:
Medical Provider Name*
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Date of Diagnosis*

MonthDayYear
Did this medical provider treat the Gamer with medication for their gaming-related injury?*

YesNo

Injury Medication 3
Please provide the name of the medication(s):*
‎

Injury Upload
Please upload any documentation regarding the diagnosis and treatment of the Gamer's injuries:

Cancelof

Medical Treatments and Plans
Please select any treatments or plans that the Gamer has received as a result of their gaming addiction:*

Individualized Educational Plan (IEP)Out-Patient CounselingMedication TherapyInpatient Treatment Gaming AddictionCognitive Behavioral Therapy for Gaming AddictionPrivate TutoringOtherNone

IEP
Please provide the name and address of the school and approximate years that the Gamer's Individualized Educational Plan (IEP) has been in place:
School's Name*
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date of IEP*

MonthDayYear

‎
End Date of IEP*

MonthDayYear

*If Gamer's IEP is still in place leave this date blank
Please upload any documentation regarding the Gamer's IEP:

Cancelof

Treatment Providers
Was the Gamer treated by a psychiatrist, counselor, or other medical provider?*

YesNo

Treatment 1
Please provide the contact information of the psychiatrist, counselor, or other medical provider(s) who treated the Gamer injuries and the dates of treatments:
Medical Provider's Name*
Phone Number*
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date of Treatment*

MonthDayYear

‎
End Date of Treatment*

MonthDayYear

*If Gamer is still being treated please leave the date blank
Did this medical provider treat the Gamer with medication?*

YesNo

Treat Medication 1
Please provide the name of the medication(s):*
‎
Was the Gamer treated by another psychiatrist, counselor, or other medical provider?*

YesNo

Treatment 2
Please provide the contact information of the second psychiatrist, counselor, or other medical provider(s) who treated the Gamer and the dates of treatments:
Medical Provider's Name*
Phone Number*
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date of Treatment*

MonthDayYear

‎
End Date of Treatment*

MonthDayYear

*If Gamer is still being treated please leave the date blank
Did this medical provider treat the Gamer with medication?*

YesNo

Treat Medication 2
Please provide the name of the medication(s):*
‎
Was the Gamer treated by another psychiatrist, counselor, or other medical provider?*

YesNo

Treatment 3
Please provide the contact information of the third psychiatrist, counselor, or other medical provider(s) who treated the Gamer and the dates of treatments:
Medical Provider's Name*
Phone Number*
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Start Date of Treatment*

MonthDayYear

‎
End Date of Treatment*

MonthDayYear

*If Gamer is still being treated please leave the date blank
Did this medical provider treat the Gamer with medication?*

YesNo

Treat Medication 3
Please provide the name of the medication(s):*
‎

Treatment Upload
Please upload any documentation regarding the Gamer's treatments:

Cancelof

Medical History
Other than the medical providers you provided above, in the last 10 years, are there other medical providers that the Gamer has seen?*

YesNo

Medical History

Hospitalization Question
In the last 10 years, has the Gamer ever been hospitalized?*

YesNo

Hospitalization

Medical History Upload
Please upload any documentation from the these medical providers or hospitals:

Cancelof

Part 4: Litigation and Criminal History
Have you ever filed a lawsuit or been a defendant in a lawsuit?*

YesNo

Adult Litigation History
For every lawsuit that you have filed or been a defendant in, please provide whether you were the Defendant or Plaintiff in the lawsuit, the type of dispute and the outcome of the lawsuit. *

Child Litigation History
Has your child ever filed a lawsuit or been a defendant in a lawsuit?*

YesNo

Child Litigation Description
For every lawsuit that the child has filed or been a defendant in, please provide whether the child was the Defendant or Plaintiff in the lawsuit, the type of dispute and the outcome of the lawsuit.*

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

YesNo

Adult Criminal History
Are you currently on probation?*

YesNo
Please provide the following information:*

Child Criminal History
Has your child ever been convicted of a misdemeanor or felony?*

YesNo

Child Criminal Description
Is your child currently on probation?*

YesNo
Please provide the following information:*

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

YesNo
Does your child receive Social Security Insurance (SSI) or Social Security Disability Insurance (SSDI) benefits?*

YesNo

We are sorry, but only the child's parents or guardians are authorized to fill out this form on the child's behalf. Please contact the child's parents or guardians and have them complete this form. Thank you.
We are sorry, but you have to be at least 18 years old to fill out this form. If you are under the age of 18, please have your parent or guardian fill out this form for you.
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