ADHD/SSRI Issues

SSRI Antidepressants Please fill out the form below to have your case evaluated. Provide as much information as possible to speed the processing of your inquiry

*Items are required. There is no charge for this evaluation.

Contact Information:

*Title: *First Name: MI: *Last Name: -- Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.   *E-mail Address: *Retype E-mail: Home Phone: - - Mobile Phone: - - Work Phone: - - ext.   *Provide at least 1 phone number. Street Address: Apt/Suite: City: State/Zip: /   What is the best way to reach you? Please provide the best place, time and method for contacting you.   Additional Contact Information: Use this area to add country codes, foreign addresses, special instructions, etc.

Injured Person Information:

Date of Birth: mm 01 02 03 04 05 06 07 08 09 10 11 12 dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 yyyy 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Whom are you inquiring on behalf of? Minor Other Self If you are NOT inquiring on your own behalf, what is your relationship? Is the person deceased? Yes No If deceased, the cause of death as stated on the death certificate:  Date of Death: mm 01 02 03 04 05 06 07 08 09 10 11 12 dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 yyyy 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Was there an autopsy performed? Yes  No  n/a

Case Information:

During what period of time was the antidepressant/SSRI taken? Start End   How old was patient when the drug was prescribed:   List names/addresses of any doctors who prescribed the drug: Why was the drug Prescribed?: Were any other medications ? Yes No If yes, list other medications taken: Was suicide attempted? Yes No Did patient hurt themselves after taking the drug? Yes No If suicide was attempted or self hurt was inflicted, was hospitalization or treatment required? Yes No If yes, please describe hospitalization or treatment: Did loved one commit suicide? Yes No Did patient become violent after taking the drug? Yes No Please describe suicidal or violent behavior: If you have stopped taking the drug, or have tried to stop taking the drug, have you experienced withdrawal side effects? Yes No If yes, please describe withdrawal side effects: Please describe other medical problems associated with the drug use:

Disclaimers:

Yes No - I agree that this matter may be referred to an attorney in Sherman Silverstein Kohl & Podolsky who may consult with an attorney in my area. Yes No - I agree that by submitting this question, I will not be charged for the initial response. I understand that I am forming only a semi-confidential relationship. Yes - - I agree that the above does not constitute a request for legal advice and that I am not forming an attorney client relationship by submitting this question. I understand that I may only retain an attorney by entering into a fee agreement, and that I am not hereby entering into a fee agreement. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter. Yes No - I would like to be contacted by telephone by an attorney as soon as possible By Clicking the appropriate box below, I agree to: