Hypnosis Stop Smoking Intake Form

HYPNOSIS EVALUATION FORM SMOKING CESSATION
The following questionnaire is a comprehensive look at your health & lifestyle. It will take about 15 to 20 minutes to complete and is imperative for successful Hypnosis sessions. Please allow yourself the time to complete without disruption. The form will not auto-save to come back to later.

Let's Begin.....

Home and Work

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Have you stopped smoking before? *
If yes, how long did you stop smoking for?
What methods did you use? Choose as many that are applicable.

Nicotine patches Chewing gum Vaping Medication Hypnotherapy Willpower
What prompted you to start smoking again?
When and where do you have your first cigarette of the day? *
Do you smoke after meals? *
Do you smoke more in social situations? *
Do you smoke more when you drink alcohol? *

Smoking History
Age You Started Smoking *
On Average How Many Cigarettes Do You Smoke Per day *
What emotions do you associate with the reason why you started smoking? *
Guilt, stress, peer pressure, etc.

Smoking History

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Where do you smoke most often? *
Has anyone in your life died due to smoking related illness? If yes, please explain. *
Please list your 3 most important life goals in the order of most importance to you *

Past Experiences
Have you ever been Hypnotized before? *

Yes No I'm not sure
If yes, please explain your experience.
Do you follow or observe any religious or meditative practices? If so, please describe:
Church, meditation, yoga, etc

Making a Commitment

Making a commitment is the first step to your success.
I pledge to myself that I am committed to stop smoking on: (DATE) *
Now sign here as as commitment to yourself. Use your finger on the screen or your computer mouse.

Clear

You're almost done, Great job!
Please tell us anything else that you may feel important or you feel is holding you back from achieving your goal to become a non smoker. Feel free to be as specific as you need to be.

You have completed the first step to becoming a non smoker.

We will reach out to you soon to discuss your form information and decide on the following steps and plan. We look forward to working with you on this journey to becoming a non-smoker.
The information contained within this form will be held in confidence and in accordance with PHIPA/PIPEDA and HIPAA requirements.
The information will be utilized in partnership with Deanna L. Byrne CHt, CMT, mNLP, Master Life Coach, and Hypnotherapist for your coaching and hypnosis sessions.
You will also be required to submit our teleconsult consent form prior to any virtual meetings or telephone calls.
Please check this box to confirm you provide express consent for us to contact you via email, phone or mail. *

I provide express consent
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