Stop Smoking Form

Stop Smoking Questionnaire

Please fill out the form and submit.

"*" indicates required fields

There are some very important questions for you to consider before you take to step to permanently choose not to smoke. Please circle the answers and add a comment if you wish to.

Is smoking the most important thing in your life right now?*

How long have you been smoking? (years)*

At what age did you begin?*

Please let us know how old you were when starting to smoke.

Can you remember the first time you smoked?*

Why do you want to stop now ?

Please describe

What methods if any have you tried before to quit smoking?

Please describe

How does your immediate family feel about your choice to stop smoking?

Please describe

Have you experienced hypnosis before?*

Do you associate positive experiences with smoking such as stress reduction, some kind of reward, something to do with your hands?*

Please list all positive aspects of smoking that you experience.

Are you willing to follow the actions required to live a smoke free life i.e. attend the sessions and listen to the accompanying MP3 for suggested period (usually 2 sessions and 3 weeks MP3)?*

How much do you spend per week on smoking?

Would you like to fund out more about our session structures and costs?*

Name*

First Last

Name

This field is for validation purposes and should be left unchanged.