Cannabis Lawsuit Questionnaire (Short Version)
Cannabis Lawsuit Questionnaire
Please complete all sections to determine case eligibility
Step 1 of 5
Section 1: Mental Health Symptoms
Which symptoms began or got worse after cannabis use? (Check all that apply)
*
Anxiety
Depression
Suicidal Thoughts
Suicide Attempt
Bipolar Episode
Psychosis / Hallucinations
Schizophrenia Diagnosis
Others
Please select at least one mental health symptom.
Have you been diagnosed with psychosis?
*
Yes
No
Unsure
Please select an option for psychosis diagnosis.
Are you currently being treated for any of these symptoms?
*
Yes
No
Please select whether you are currently being treated.
Have you been diagnosed with Schizophrenia?
*
Yes
No
Please select whether you have been diagnosed with Schizophrenia.
Section 2: Cannabis Use
Was the cannabis purchased from a licensed dispensary?
*
Yes
No
Please select whether cannabis was purchased from a licensed dispensary.
In which state(s) was it purchased?
*
Select State to Add
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Please select at least one state where cannabis was purchased.
How often was cannabis used?
*
Daily
Weekly
Monthly
Less
Please select how often cannabis was used.
What product types were used? (e.g., flower, vape, edible)
*
Please specify what product types were used.
Do you know the THC potency?
*
<20%
20-30%
31-60%
>60%
Don't Know
Please select a THC potency option.
When did you buy cannabis for the first time?
*
Please enter when you first purchased cannabis.
When was the last time you purchased cannabis?
*
Please enter when you last purchased cannabis.
Section 3: Legal & Substance Screening
Have you used meth, cocaine, heroin, or fentanyl in the last 2 years?
*
Yes
No
Please select whether you have used hard drugs in the last 2 years.
Are you currently working with another law firm for this case?
*
Yes
No
Please select whether you are working with another law firm.
Any violent criminal charges in the last 10 years?
*
Yes
No
Please select whether you have violent criminal charges.
Section 4: Authorization
Do you agree to receive legal paperwork and HIPAA release via text or email?
*
Yes
No
Please select whether you agree to HIPAA release.
Section 5: Your Contact Details
Full Legal Name:
*
Please enter your full legal name.
Date of Birth (MM/DD/YYYY):
*
Please enter your date of birth.
Social Security Number (Last 4 Digits):
*
Please enter the last 4 digits of your Social Security Number.
Full Address:
*
Please enter your full address.
Phone Number:
*
Please enter your phone number.
Email Address:
*
Please enter your email address.
Relationship to Injured Party:
*
Self
Parent
Legal Guardian
Estate Representative
Please select your relationship to the injured party.
Additional Information:
Please enter additional information.
Please upload any supporting documents or pictures
📸
Click to upload Files
Supported formats: PDF, JPG, PNG, GIF (Max 10MB)
Please upload a picture.
Previous
Next
Submit Application