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Healthy Gamers – Big Winners Intake Form
HEALTHY GAMERS – BIG WINNERS
Participant Intake & Baseline Questionnaire
Section 1 – Participant Profile
Full Name
Age
Grade Level
City / State
Parent/Guardian Name
Parent/Guardian Email
Parent/Guardian Phone
Primary Game(s) You Play Most Often
Do you participate in organized esports?
Yes
No
Section 2 – Gaming Habits
Weekday Gaming Hours
0–1
1–3
3–5
5–7
7+
Weekend Gaming Hours
0–2
2–4
4–6
6–8
8+
What time do you usually stop gaming?
Before 9PM
9–10PM
10–11PM
11PM–12AM
After Midnight
Section 3 – Self-Assessment (1–5 Scale)
I feel in control of my gaming time.
1
2
3
4
5
Gaming interferes with my sleep.
1
2
3
4
5
Gaming interferes with school performance.
1
2
3
4
5
Gaming helps me feel competent or skilled.
1
2
3
4
5
I use gaming to escape stress.
1
2
3
4
5
I feel respected in my gaming community.
1
2
3
4
5
I feel confident about my future.
1
2
3
4
5
I feel physically healthy most days.
1
2
3
4
5
Section 9 – Agreement
Participant Agreement: I understand this program is designed to support healthy habits, mentorship, and personal development.
Parent Agreement: I give permission for my child to participate in this mentoring program.
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