Form Page

First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Do you or your child have an addiction to video games?*

Yes

No

How old is the person that has a video game addiction?*

How many hours a day on average do they play video games?*

In what state do you currently reside?*

What games do you or your child commonly play?*

Fortnite

Roblox

Minecraft

Call of Duty

Others

What console(s) are used for the gaming?*

XBOX

PlayStation

Switch

PC

Other

How has video game addiction negatively impacted you or your child’s life?*

When would be a good time to call you?

Central Time

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I Consent