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DIGITAL DETOX INITIATIVE
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Intake form
Help us serve you better
Name
*
Email address
*
What is your primary reason for seeking help with digital addiction?
Please select at least one option.
Personal addiction
Family member's addiction
Work-related issues
Mental health concerns
Social isolation
Other concerns
How long have you been experiencing issues related to digital addiction?
What digital devices do you or your family members use most frequently?
Please select at least one option.
Smartphone
Tablet
Laptop
Desktop computer
Smart TV
Gaming console
Which social media platforms do you regularly use?
Please select at least one option.
Facebook
Instagram
Twitter
TikTok
LinkedIn
Snapchat
How many hours per day do you typically spend on digital devices?
What strategies have you tried to reduce your digital usage?
Are you open to participating in group therapy sessions?
Select
Yes
No
Maybe
What type of intervention are you interested in?
Please select at least one option.
Individual counseling
Family counseling
Workshops
Online resources
Support groups
Do you have any existing mental health conditions?
Please select at least one option.
Anxiety
Depression
ADHD
OCD
None
What age group do you belong to?
Select
Under 18
18-24
25-34
35-44
45-54
55 and older
How did you hear about the digital detox initiative?
Select
Referral
Social media
Search engine
Event
Additional questions or comments
Submit
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