Press Pause: Helping Kids Reclaim Balance

Are you filling this on behalf of someone else *YesNo

Do you or your child average 3 hours of video game playing a day or roughly 15 hours a week *YesNo

Were you under the age of 22 when you developed a video game addiction? *YesNo

What Platforms Do you play games on?

Platforms

Other

Epic Games Gamertag

Nintendo Gamertag

Roblox Gamertag

Activision Blizzard Gamertag

Mobile Gamertag

PlayStation Gamertag

Xbox Gamertag

Steam Profile Name

Microsoft (Xbox for Windows) Gamertag

Other Gamertag

How Has Gaming Addiction Affected You? *Poor schoolwork or performanceWithdrawal symptoms when game endsLoss of interest in activitiesChronic school absencesServere grade declineDeceives family and steals moneyDecreased personal hygiene due to addictionFailed attempt to stay off

Name *

Phone Number

Email Address *

Date of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Have You Sought Medical or Professional HelpYesNo

Are you currently retained with another attorney regarding this?YesNo

Disclaimer

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By clicking the "Submit" button, I agree to the policies and disclaimers, including arbitration provision therein, and consent to receive marketing emails, calls, and/or texts, including those made using an automated system and/or artificial/prerecorded voice message, from or on behalf of MTMC ("MTMC" or "The Nurses"), regarding their services in response to my inquiry. I understand my consent to receive automated marketing calls/texts is not required as a condition of purchasing any services. I can revoke my consent at any time. Review MTMC's Terms and Conditions and Privacy Policy here.

Consent to Respond to Marketing

By clicking “Submit”, I agree to the Terms of the Policies and Procedures of the referenced entity, including individual arbitration provisions therein. I also consent to receive marketing emails, calls, and/or text messages, including those made using an automated system and/or artificial/prerecorded voice message (including artificial intelligence (AI)-generated voices), from or on behalf of the referenced entity regarding its services and/or my inquiry at the telephone number provided above, even if currently listed on any state or federal Do Not Call registry. I understand that my consent to receive automated marketing calls/texts is not required as a condition of purchasing any services, and that I may opt out of such calls/texts at any time.

Press Pause: Helping Kids Reclaim Balance

A campaign by MTMC – The Nurses