VGA Form - TLL

1

Have you or your child regularly spent 2 or more hours a day playing video games at some point in life?* This field is required.

Yes

No

I'm not sure

2

Did you or your child drop out of high school or college?* This field is required.

Yes

No

Other - I was homeschooled

3

Have you or your child been diagnosed with a mental or physical condition that could be linked to frequent gaming? For example: ADHD/ADD, depression, anxiety, panic disorder, social phobia, carpal tunnel, seizures?* This field is required.

Yes

No

I'm not sure

4

Which state do you live in?* This field is required.

5

Name* This field is required.

First Name

Last Name

6

Email* This field is required.

example@example.com

7

Phone Number* This field is required.

Please enter a valid phone number.

8

Legal Disclosure* This field is required.By checking this box, I agree to the terms and consent to be contacted.

9

Consent to Contact* This field is required.By checking these boxes, I agree to the terms and consent to be contacted.

10

Please verify that you are human* This field is required.

11

Based on your answers, we are unable to assist you with this type of case. If you think this is a mistake and you may qualify, feel free to contact us.