JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Join Help Me Now Intake Form
We are collecting data to clarify the demographics of those who were not properly served by their attorneys.
* Indicates required question
Email
*
Record my email address with my response
Carl Cummings
*
Your answer
Age
*
Choose
45
Gender
*
Male
Female
Trans Male
Trans Female
Prefer not to say
Race
*
Black or of African Descent
White or of European Descent
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
Asian
Native American or Alaskan
Other
705 Kimbrough st
*
Your answer
Douglas
*
Your answer
Georgia
*
Your answer
32034
*
Your answer
District or Neighbowrhood
*
Your answer
*
Your answer
32,000
*
Your answer
9043518436
*
Your answer
youramericanadvocacy@gmail.com
*
Your answer
What is the best way to contact you?
*
Email
Phone
Mail
What is your education level
*
No high school diploma
High school diploma
Associate's degree or 2 years of college
Master's degree
Ph.D. or professional degree
What is your annual income?
*
$0-$25,000
$25,001 - $50,000
$50.001 - $75,000
$75,001 - $100,000
$100,001 - $150,000
$150,000-$200,000
More than $200,000
Other:
Are you a property owner?
*
Yes
No
Have you ever had a job-related injury and received workman compensation benefits?
*
Yes
No
If yes, in what state?
Your answer
Did you lose work?
*
Yes
No
If yes, how many days?
Your answer
Did you have surgery?
*
Yes
No
Employer's Name
*
Your answer
Employer's City and State
*
Your answer
Years of employment at time of injury
*
Your answer
Position or job title
*
Your answer
Did you hire an attorney?
*
Yes
No
If yes, what is the name of the Attorney? If no, put n/a
*
Your answer
What is the name of the firm that the attorney works for?
Your answer
What state is the law firm based?
Your answer
How did you find the attorney?
*
Yellow pages
Referral by friend
Social Media
Goggle search
Not applicable
Other:
How did the attorney communicate with you?
*
Email
Phone
Email and Phone
Text messages
Not applicable
Other:
Was a settlement reached in your case?
*
Yes
No
Not applicable
Who suggested the amount?
*
Option 1
Was the first offer accepted?
*
Yes
No
If no was the amount lower?
*
Yes
No
Not applicable
Other:
Did your attorney request or require a physician to examine you before presenting the offer to you?
*
Yes
No
Not applicable
During your conversation with the attorney, was the word, "Money" used?
*
Yes
No
I don't remember
Not applicable
If yes, how many times was the word "money" used?
Your answer
How was the word "money" used in a sentence or phrase?
Option 1
Clear selection
Did your attorney ever commit any unethical acts?
*
Yes
No
Maybe
Not applicable
Did your attorney encourage you to accept an unacceptable offer?
*
Yes
No
Not applicable
Summarize your thoughts on your attorney and the workman compensation case.
*
Your answer
Did you ever visit a Workman Compensation Doctor?
*
Yes
No
I don't remember
If you answered yes, how many times did you visit the workman compensation doctor?
Your answer
What was the workman compensation doctor's name?
Your answer
Was transportation provided to the doctor?
Yes
No
I don't remember
Clear selection
What is the address of the workman compensation doctor?
Your answer
How would you describe the workman compensation doctor's attitude towards you?
Your answer
Did you write a review of the workman compensation doctor?
*
Yes
No
I don't remember
I did not go to a workman compensation doctor
Did you ever have any involvement or request from a Judge regarding your case?
*
Yes
No
I don't remember
If you answered yes to the question above, what was the name of the Judge?
Your answer
Please describe the information received or requested from the Judge.
Your answer
Directly pertaining to employees associated with the workman compensation case. Do you believe the workman compensation claim adjuster acted in good faith?
*
Yes
No
Not applicable
On a scale of 1 to 10, with 1 being the lowest and 10 being the highest number given, please rate your Workman Compensation Experience.
*
1
2
3
4
5
6
7
8
9
10
How did you hear about us?
*
Church Bulletin
Facebook
Instagram
Word of Mouth
Other:
Donate Today. How can I help? You can help by making a generous contribution to Join Help Me Now to broaden our scope in many more communities throughout our state for claimants seeking restitution for negligence by the hands of their hired attorney on a dissatisfied workman compensation claim case. Your participation is so needed. Thank you. Scan the QRC code below to donate or click this link:
http://paypal.me/joinhelpnow.
Your answer
Send me a copy of my responses.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
