Smoking Cessation Registration
Whether this is your first attempt at quitting smoking or your 10th, the Pride Center is here to help you succeed and quit for good! After completing this form, a tobacco treatment specialist will reach out to you to schedule an intake assessment.
(i.e.: she/her, he/him, they/them)
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Date of Birth
At what age did you start using tobacco on a regular basis?
In the past six months, what is the average number of cigarettes (or other tobacco products) you have used per day?
Are you currently using an electronic nicotine delivery system (e-cigarette, vape, etc.)?
How many times have you made a serious attempt to quit smoking or using tobacco products?
More than 3
If you have tried to quit in the past, what methods have you used? (check all that apply)
Nicotine nasal spray
Chantix / varenicline
If you attempted to quit in the past before and found success, how long were you able to stay nicotine-free?
Should be Empty: