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Family Digital Safety - Pre-Assessment intake form.

Your privacy matters to us. All information submitted on this form is confidential and will only be used by Personal Systems / Family Guardian Network to prepare for your home assessment. We will never sell, share, or disclose your information to any third party for any reason.

Questions? Call or text Davin directly at (865) 242-2500.

Contact Information

Parent(s) Full Name

*

Phone Number

*

Home Address

*

Email Address

*

City

*

Preferred Assessment Date

Children & Household

Child 1 Name & Age

*

Child 2 Name & Age

Child 3 Name & Age

Child 4 Name & Age

Other adults in the home

What kind of phones do your children have?

*

What kind of phones do your children have?

A

iPhone

B

Android

C

Both

D

No phones yet

Network Setup

Internet Service Provider

*

Router Setup

*

Current parental controls in place

*

Current parental controls in place

Router-level filtering

Device-level monitoring (OS/App)

None currently in place

Devices

All internet-connected devices in the home

*

All internet-connected devices in the home

Smart TVs

Game Consoles

Laptops/Desktops

Tablets

Smart Home Devices (Alexa, Ring, etc.)

How many TVs?

*

How many computers?

*

How many kids' phones?

*

Platforms & Supervision

Platforms/Apps kids use

*

Platforms/Apps kids use

Roblox

Minecraft

Fortnite

Discord

TikTok

Instagram

Snapchat

YouTube

YouTube Kids

BeReal

Other

Bedroom device supervision rules

*

Current screen time rules

*

Concerns

Top concerns

*

Top concerns

Adult content exposure

Predators/Strangers

Cyberbullying

Screen time management

Gaming addiction

Social media pressure

Privacy/Personal data

Hacking/Viruses

Backup/Data loss

Tech comfort level

*

Tech comfort level

A

1 - I'm not comfortable with tech and need help with almost everything.

B

2 - I know the basics, but I often need support.

C

3 - I'm moderately comfortable, but could use some guidance.

D

4 - I'm very comfortable with tech and can handle most setups.

E

5 - I'm a power user and love managing my own tech.

Has anything negative happened online before?

*

Has anything negative happened online before?

A

Yes (please describe below)

B

No

Anything else?

Any additional concerns or questions?

How did you hear about us?

*