Smoking Cessation Appointment Form
Please fill out the following form. This will help me to determine if you are ready, in the right frame of mind, to stop smoking for good and make a complete success of your appointment! Thank you.
Name
First Name
Last Name
Date of Birth
Address
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Email
example@example.com
GP Name and Address
Any Medications, Illnesses, Diagnoses/Heart or Thyroid Issues etc (past and present)
Marital Status
Number of Children (if applicable)
Why do you wish to stop smoking?
How many do you smoke in a day?
Are there any times you are more likely to smoke than others? eg when stressed, happy, sad, etc...
Have you tried to stop before? What method did you use? How long did you stop for? (if applicable)
Have you reached a point where you are completely sick of smoking?
Are you stopping completely for yourself, or for someone else (eg doctor, spouse, child, friend)
As a hypnotherapist, I can give you the tools to stop, but only YOU can make it work! Are you 100% ready and committed to the work we will do to ensure you stop smoking for good?
Where did you hear about my services?
Submit
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