Smoking Cessation Intake Form
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Welcome to my short intake form! All answers are confidential.
Are you over 18?
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?
Why do you smoke?
To take a break
To be social
To have something to do with my hands
To have something to do with my mouth
What is your routine for smoking?
If you have ever stopped before, what worked for you?
Other types of medication
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
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I agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law