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marian@quadcitieshypnosis.com
Smoking Cessation Intake Form
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Smoking Questionnaire
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Instructions
(optional)
Welcome to my short intake form! All answers are confidential.
Name
Email Address
Phone Number
Are you over 18?
Yes
No
If you have any physical or mental health diagnoses, are you under the care of someone with the correct license to treat that condition?
Yes I have licensed healthcare for my diagnosis
No I don't have licensed healthcare for my diagnosis
I don't have any diagnoses
What, if any, are your spiritual beliefs?
What, if any, is your experience with hypnosis/NLP?
When you had your first cigarette, did you like it?
Yes
No
Why do you smoke?
Stress
Comfort
Boredom
Anger
Anxiety
To take a break
To be social
To have something to do with my hands
To have something to do with my mouth
Other
What is your routine for smoking?
If you have ever stopped before, what worked for you?
(optional)
Chantix
Patches
Hypnosis
Cold Turkey
Pregnancy
Other types of medication
Other
What are you going to be believing about yourself once you have made this change?
How are you going to reward yourself?
Confidentiality, Self-Responsibility, Cancellation Policy
I agree to the
terms and conditions
Signature
I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law