The Digitox Restore Application / Interest Form 
Thanks for filling out the form below. This helps to determine how best Digitox can support your family. 

Once the form is returned we will contact you via email or phone. 

PLEASE NOTE- Trigger Warning: There are extensive questions asked regarding mental health, please be aware of your own self care & seek support if triggered.                                                                                                             

All information is 100% safe and confidential and will not be shared with anyone outside of DigiTox. Thankyou!
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Email *
Your Name *
Today's Date *
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Phone Number / Please download WhatsApp if you live outside of Australia AND country code please/ country name. *
1-How many kids living in the home?
2-What ages are they?
Please answer the below questions for each child in the home - even if they don't seem to have an issue with technology.
 *
What age did your child start using technology? *
How many hours does each child spend on technology daily? *
Does Your child sleep with any technology in the bedroom? *
What social media do they use?  *
What tech based games do they play? *
What do our kids use their devices for?  *
Required
What devices do your kids play on? *
Required
How does your child react when you tell them to get off the screen time device? *
Are you a single parent? *
Does your husband/ wife/ partner/ ex-partner agree with your concerns regarding this issue? *
Does your child go to school? *
Required
Did your child suffer mental health or trauma before the excessive device use?  *
Has your child ever vandalized the house/ been violent towards others? *
Are you aware of your child engaging in porn? *
Does your child self-harm? If so, do they have support structure in place? *
Has Your Child been diagnosed with or do you suspect : *
Required
Is your child medicated for any mental health conditions? *
Is your child currently seeing a therapist? *
Are you aware of your child using alcohol / drugs? *
What are your main concerns with internet use in your household? *
What are you currently doing to try to manage screen time ?  *
What would you like to see change? *
DIGITOX PRE REQUISITE
Thank you for taking the time to fill this form. 

Please take some time out to relax and make sure you feel ok after answering these questions if you feel triggered by any of the content. :) 
We will email you as soon as we have received your application.

Please read the Terms & Conditions of The Digitox Restore Program here https://digitox.com.au/terms
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