• SOCIAL MEDIA TEEN INJURY CLAIM

    GROVE AND ASSOCIATES, PC INTAKE QUESTIONNAIRE
  • Confidential — Attorney / Prospective Client Intake
  • IMPORTANT INFORMATION
    This questionnaire is designed to assist the law firm in evaluating a potential claim involving a minor who allegedly suffered psychological, emotional, behavioral, or other damages associated with social-media use or online conduct. Answer completely and accurately. If unknown, write “Unknown.” Do not exaggerate symptoms, events, or damages.
    • I. PARENT / LEGAL GUARDIAN INFORMATION 
    • Format: (000) 000-0000.
    • Is the person completing this questionnaire the minor's legal parent or guardian?
    • Custody, guardianship, or parental-rights issues involving the minor?
    • II. MINOR'S INFORMATION 
    • Date of Birth:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Other name, username, or online identity relevant to this matter?
    • Please provide Username(s), screen name(s), or account name(s):
    • III. SOCIAL-MEDIA PLATFORM(S) 
    • Social Media Platforms(s):
    • Approximate date minor began using platform:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Hours per day platform used
    • IV. DESCRIPTION OF THE ALLEGED HARM 
    • What initially caused concern:
    • V. ALLEGED SOCIAL-MEDIA CONDUCT 
    • Alleged Social media Conducts:
    • VI. TIMELINE 
    • Social-media use began:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Concerning conduct/content began:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Was account restricted/deleted/discontinued:
    • Post-action outcome options
    • VII. PSYCHOLOGICAL / EMOTIONAL SYMPTOMS 
    • Psychological/ emotional Symptoms:
    • How frequently did they occur?
    • How severe were they at their worst?
    • VIII. MEDICAL / MENTAL-HEALTH TREATMENT 
    • Medical/ Mental health Treatment:
    • First treatment date:
       - -
      2 digit month, 2 digit day, 4 digit year
    • Last treatment date:
       - -
      2 digit month, 2 digit day, 4 digit year
    • IX. PRIOR HISTORY / OTHER POTENTIAL CAUSES 
    • Prior documented mental-health/behavioral/emotional symptoms:
    • Significant family/school/relationship/medical circumstances during same period.
    • Offline bullying/harassment:
    • Other significant traumatic event during relevant period:
    • X. SCHOOL IMPACT 
    • School Impact Factors
    • Approximate date school problems began:
       - -
      2 digit month, 2 digit day, 4 digit year
    • School documented changes:
    • XI. SOCIAL / FAMILY IMPACT 
    • Social / Family Impact
    • XII. ECONOMIC DAMAGES 
    • Economic Damages Expenses
    • Parent/guardian missed work:
    • XIII. EVIDENCE AND DOCUMENT PRESERVATION 
    • Evidence types preserved
    • Relevant content deleted:
    • Account deleted/suspended/restricted:
    • Logged Screen Time for each platform:
    • XIV. PLATFORM REPORTING 
    • Concerning content/conduct reported to platform:
    • Type of Report
    • Platform response:
    • XVI. PRIOR OR CURRENT LEGAL CLAIMS 
    • Prior lawsuit concerning these events:
    • Another attorney consulted:
    • Another attorney retained:
    • Settlement/release/waiver/arbitration agreement signed:
    • XVII. INSURANCE / BENEFITS 
    • INSURANCE / BENEFITS Options
    • XVIII. IMMEDIATE SAFETY SCREEN 
    • Is the minor currently expressing suicidal thoughts, intent to harm themselves, or an immediate intention to hurt another person?
    • If YES or UNKNOWN and there is an immediate safety concern, treat the matter as an emergency rather than a routine legal intake. Contact emergency services or an appropriate crisis resource immediately.

    • CLIENT CERTIFICATION

    • I certify that the information provided in this questionnaire is true and accurate to the best of my knowledge. I understand that submitting this questionnaire does not create an attorney-client relationship unless and until the law firm agrees in writing to represent me.
    • Date:
       - -
      2 digit month, 2 digit day, 4 digit year
    • CONFIDENTIAL — SOCIAL MEDIA TEEN INJURY CLAIM INTAKE

  • CONTINGENCY FEE AGREEMENT

  • This Agreement is made between as   *   parent and legal guardian of   *   "the Ward", GROVE AND ASSOCIATES PC ("Attorney"), 36700 Woodward Avenue, Suite 107, Bloomfield Hills, Michigan 48304, and THE LAW OFFICES MCSWEENY LANGEVIN ("Attorney"), 2116 2nd Avenue South, Minneapolis, Minnesota 55404.

  • (THIS IS A CONTRACT BETWEEN THE CLIENT AND LAW FIRMS TO EVALUATE, INVESTIGATE, AND LITIGATE POTENTIAL CLAIMS AGAINST SOCIAL MEDIA COMPANIES. THIS IS NOT PART OF A "CLASS ACTION LAWSUIT", EACH CASE IS EVALUATED AND PROSECUTED BASED ON ITS INDIVIDUAL MERITS.)

    1. The undersigned Client, on the following terms and conditions, requests and authorizes Attorneys to represent Client as legal counsel for all purposes in connection with:
       
    2. Client agrees and acknowledges that this Agreement does not require Attorney to provide any legal services other than those described above and Client further agrees and acknowledges that this agreement does not require Attorney to provide any legal services for appeals or post judgment relief unless specifically agreed to in writing by both parties.
    3. Client has been advised that he may represent himself without an attorney, but elects to retain Attorneys who agrees to represent Client. Client agrees to cooperate fully with Attorneys and to sign all forms, authorizations and documents deemed necessary in the sole discretion of Attorney. Neither party will settle or otherwise dispose of the case without the other's approval. Attorneys may, in their discretion, withdraw from the case at any time with reasonable notice to Client.
    4. Client agrees to reimburse Attorneys all costs incurred by Attorneys on behalf of Client in pursuit of Client's interests as defined in this Agreement "only if client receives compensation in the form of a settlement, Arbitration award, Verdict or Judgment." Said costs include but are not limited to court fees, filing fees (including late fees), investigation fees, telephone charges, mileage, postage, travel, delivery fees, experts, photocopies/photographs and any other costs deemed necessary in the sole discretion of the Attorneys in the handling of Client's legal matter(s).
    5. Client agrees to employ Attorneys on a contingent fee of One-Third (1/3) of the net recovery of any settlement, verdict, award or recovery. The net recovery shall mean the amount remaining after deducting from the gross recovery all costs, expenses and disbursements chargeable to the enforcement of the claim or the prosecution of the action. The gross recovery shall include total monies recovered, including, but not limited to, all past benefits, the present value of future benefits all interest and taxable costs.
    6. If actual attorney fees are awarded, recovered or paid pursuant to a settlement, Attorneys may at its sole and exclusive option, elect to add this attorney fee to the gross recovery for purposes of computing the one-third (1/3) fee, or it may accept the actual attorney fee instead of the one-third (1/3) fee.
    7. In the event that any settlement, verdict, award or recovery is to be paid in installments, Client agrees that Attorney may, at its sole and exclusive option, elect to take the attorney fee in full at the time of the initial payment(s), or may take the attorney fees from any installment payment. In the event that Attorney elects to take the attorney fee in full at the time of the initial installment payment(s), the attorney fee shall be on the one third (1/3) of the present cash value of all of the present and future payments, after deduction of the costs and expenses as previously set forth.
    8. If there is no settlement, verdict, award or recovery in this matter, no attorney fees will be due. At the conclusion of this matter, Attorneys shall provide Client with a written statement of the matter's outcome and, if there is any settlement, verdict, award or recovery, show the remittance to Client and the method of its determination.
    9. Client authorizes Attorneys, in their sole discretion, to retain possession or dispose of Client file(s) and records after 5 years of the date of Attorneys last representation of the Client in the particular matter as to which the file is made. However, Client may obtain, after providing 30 days written notice to Attorneys at Attorneys addresses before the 5th annual anniversary date of the last representation, a copy of Client's files provided that Client reimburses Attorneys for the reasonable cost of a copy of the files requested.
    10. Client agrees that Attorneys have made no promises or guarantees regarding the outcome of Client's legal matter, claim or lawsuit. Client agrees and understands that all representations made by Attorneys are given in good faith and based upon their professional judgment.
    11. Client binds his heirs, executors, and legal representatives to the terms and conditions set forth in this Agreement. Client has read this contract, received a copy of it, and agrees to the terms and conditions. There are no other agreements, oral or otherwise, between Client and Attorneys.
    12. In the event that there is any settlement, verdict, award or recovery in this matter, Client authorizes and grants to Attorneys the power-of-attorney to sign on Client's behalf any check or draft received and to deposit said funds in the Attorneys (IOLTA) Trust Account for disbursement in accordance with this Agreement.
    13. Attorneys, at their discretion, may withdraw from representation of Client at any time and on reasonable notice to Client. If Attorneys have filed an appearance on behalf of Client, Attorneys, at their discretion, may petition the court at any time and on reasonable notice to Client to allow Attorneys to withdraw from representation of Client.
    14. Client understands and agrees that Attorneys shall have all general, possessory or retaining liens, and all special or charging liens known to the common law, in addition to any statutory lien, upon Client's claim in this matter. Such lien shall attach to any settlement, verdict, award or recovery in the Client's favor and to the proceeds thereof into whomsoever's hands they may come. Attorneys shall not be, in any way, obligated to waive its Attorneys lien until its Attorney fees and any and all disbursements made upon Client's behalf have been fully paid. Attorneys shall not be liable to the Client in any way whatsoever for any loss Client may incur or suffer because of Attorneys exercising its attorneys lien in order to secure full payment of its legal fees and proper costs, expenses and disbursements under this Agreement.
    15. Michigan Court Rule 8.121 and the laws of the State of Michigan govern this Agreement.
    Grove and Associates, PC
    36700 Woodward Avenue, Suite 107
    Bloomfield Hills, MI 48304
    Phone: (248) 554-3464    		 McSweeney/Langevin
    2116 2nd Avenue South
    Minneapolis, MN 55404
    Phone: (877) 542-4646
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
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