What is your relationship to the teen? *

Tell us about him and what are the main things he's struggling with? *

How much time does your son spend in front of screens? *

Does your son struggle with pornography? *

Are you aware of any sexting? *

Does your son avoid social situations? *

Yes

No

Has your son stopped participating in activities that he once found enjoyable? *

Yes

No

Does your son want to be alone more than other children his age? *

Yes

No

Has your son ever become physically aggressive? *

Yes

No

Has your son participated in self harm (cutting, scratching, suicide threats)? *

Yes

No

Does your son argue or become verbally disrespectful? *

Yes

No

Is he currently living in your home? *

Yes

No

Are there any pending legal charges or issues regarding your son? *

Yes

No

What happens if structure, boundaries are placed regarding devices? *

On a scale of 0 - 5 how important is it for you to get these problems corrected? *

1

2

3

4

5

What is affordable for your family? *

Do you have any health insurance that might help? *

Yes

No

Is your son willing to attend treatment? *

Yes

No

Will you need a safe transportation option? *

Yes

No

Are there any special mental health, testing or educational concerns?

Are you willing to invest $5,000 to help your son overcome his addiction(s)? *

Yes

No

First Name *

Last Name *

Phone *

Email *

When's the best time to call?