Lifetime Benefits — free online evaluation

		All responses are confidential. Please visit our privacy policy.
		This service is available only for children born in the United States.
		Please use the submission form below or call 1-800-888-LAWS.
		This evaluation is free.

Does your child have cerebral palsy or brain damage?		Yes No Not sure
How long did mom carry?		40+ weeks 37–40 weeks 32–36 weeks less than 32 weeks
Was mom's labor induced?		Yes No Not sure
Baby’s birth weight?		lbs. oz.
How did mom deliver?		Natural Emergency C-section Planned C-section
Was the delivery difficult?		Yes No Not sure
Was the delivery delayed?		Yes No Not sure
Was there meconium in the amniotic fluid?		Yes No Not sure
Was mom connected to an electronic fetal monitor?		Yes No Not sure
Was the baby’s heart rate dropping prior to birth?		Yes No Not sure
Did the doctor use forceps or vacuum extraction?		Yes No Not sure
Was the baby breathing after birth?		Yes No Not sure
Did the baby require resuscitation / CPR?		Yes No Not sure
Did your baby have seizures, shakes or tremors within 48 hours after delivery?		Yes No Not sure
Was your baby transferred to the Neonatal Intensive Care Unit?		Yes...How long? No Not sure
Did mom have high blood pressure or diabetes?		Yes No Not sure
Did mom have fever during labor?		Yes No Not sure
Was the pregnancy high risk?		Yes No Not sure
Did your baby have an MRI, Ultrasound, or CT of the brain?		Yes No Not sure
*Your first name
*Your last name
*Phone number with area code
Work number with area code
Cell phone number with area code
Alternate number with area code
E-mail address
Home address
City
State
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Child’s first name
Child’s last name
*Child’s date of birth (mm/dd/yyyy)		/ /
*State of birth		Select a State ------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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
In the space provided, tell us in your own words what you feel went wrong.

The doctor will review your information and respond within 24 hours.

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