• PART 1

  • PERSONAL INFORMATION

  • Personal Information

  • Are you the video game player or are you the parent/guardian of the video game player?*
  • Are You Over the Age of 18

  • We are sorry, but you have to be at least 18 years old to fill out this form. If you are under the age of 18, please have your parent or guardian fill out this form for you. 

  • We are sorry, but only the child's parents or guardians are authorized to fill out this form on the child's behalf. Please contact the child's parents or guardians and have them complete this form. Thank you.

  • Parent or Guardian's Information

    Please provide your contact information
  • Format: (000) 000-0000.
  • Is the Gamer's Address the same as yours?
  • What is Your Relationship to the Gamer?
  • What is your Current Marital Status?
  • What type of custody do you have of your child?

  • Gamer's Information

    Please provide your contact information
  • Format: (000) 000-0000.

  • PART 2

  • VIDEO GAME INFORMATION

  • Video Game Information

  • Gaming Console Information

  • Select the gaming consoles and/or phones the gamer currently plays or has played video games on?

  • Xbox Gaming Questions

  • Provide the Gamer's Xbox Gamertag(s) and email address(es) associated with the gamers Xbox account?

  • Did you create this account for your child?
  • Where you aware that your child created this account?

  • PlayStation Gaming Questions

  • Provide the Gamer's PSN ID(s) and email address(es) associated with the Gamer's PlayStation account(s)?

  • Did you create this account for your child?
  • Where you aware that your child created this account?

  • Nintendo Switch Gaming Questions

  • Provide the Gamer's Nintendo Switch username(s) and email address(es) associated with the Gamer's Nintendo Switch account(s)?

  • Did you create this account for your child?
  • Where you aware that your child created this account?

  • Gaming Subscription Questions

  • Select the Gamer's Xbox subscriptions (if applicable)
  • Select the Gamer's PlayStation subscriptions (if applicable)
  • Select any other subscriptions (if applicable)?

  • Video Games

  • Select the videos games the Gamer plays or has played for more than 50 hours:

  • Gaming History

  • For each game selected, provide the following if applicable:


    1. The year the Gamer started and stopped playing the game;

    2. The average amount of hours the gamer played per week.

    3. The amount the Gamer has spent on in-game content such as loot, level up options, rewards, badges, additional game content, etc;

    4. The method of payment used to make in-game purchases.

    • Minecraft 
    • Minecraft

      Minecraft

    • Roblox 
    • Roblox

      Roblox

    • Fortnite 
    • Fortnite

      Fortnite

    • Call of Duty Series 
    • Call of Duty Series

      Call of Duty Series

  • PART 3

  • INJURIES AND MEDICAL INFORMATION

  • Video Games Related Injuries

  • Negative Gaming Symptoms

  • Has the Gamer experienced any of the following symptoms that have lasted more than 12 months:

  • Gaming Injuries and Diagnoses

  • Has the Gamer Been Diagnosed or Experienced any of the Following Injuries:
    • Medical Provider 

    • Medical Provider Information

    • Provide:

      (1) The Contact Information of the Medical Provider(s) Who Diagnosed or Treated the Gamer; and

      (2) Date of Diagnosis(es)

    • Date of Diagnosis
       - -
    • Format: (000) 000-0000.
    • Did this medical provider treat the Gamer with medication for their gaming-related injury?
    • Was the Gamer treated by another doctor for their gaming-related injury?
    • Medical Provider 1 

    • Second Medical Provider Information

    • Date of Diagnosis
       - -
    • Format: (000) 000-0000.
    • Did this medical provider treat the Gamer with medication for their gaming-related injury?
    • Was the Gamer treated by another doctor for their gaming-related injury?
    • Medical Provider 1 

    • Third Medical Provider Information

    • Date of Diagnosis
       - -
    • Format: (000) 000-0000.
    • Did this medical provider treat the Gamer with medication for their gaming-related injury?
    • Was the Gamer treated by another doctor for their gaming-related injury?

  • Please upload any documentation regarding the diagnosis and treatment of the Gamer's injuries:

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  • Medical Treatments and Plans

  • Please select any treatments or plans that the Gamer has received as a result of their gaming addiction:
  • Was the Gamer treated by a psychiatrist, counselor, or other medical provider?
    • IEP Treatment 

    • Provide the name and address of the school and approximate years that the Gamer's Individualized Educational Plan (IEP) has been in place:

    • State Date of IEP
       - -
    • End Date of IEP
       - -
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    • Counselor Treatment 

    • Please provide the contact information of the psychiatrist, counselor, or other medical provider(s) who treated the Gamer injuries and the dates of treatments:

    • Format: (000) 000-0000.
    • Start Date of Treatment
       - -
    • End Date of Treatment
       - -
    • Did this medical provider treat the Gamer with medication for their gaming-related injury?
    • Was the Gamer treated by another doctor for their gaming-related injury?
    • Counselor Treatment 

    • Please provide the contact information of the psychiatrist, counselor, or other medical provider(s) who treated the Gamer injuries and the dates of treatments:

    • Format: (000) 000-0000.
    • Start Date of Treatment
       - -
    • End Date of Treatment
       - -
    • Did this medical provider treat the Gamer with medication for their gaming-related injury?

  • Please upload any documentation regarding the Gamer's Treatment:

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  • PART 4

  • Litigation and Criminal History

  • Does the Gamer receive Social Security Insurance (SSI) Social Security Disability Insurance (SSDI) benefits?
  • Has the Gamer ever filed a lawsuit or been a defendant in a lawsuit?
  • Has the Gamer every been convicted of a misdemeanor or felony?
  • Is the Gamer currently on probation?
  • Should be Empty: