Stop Smoking Registration

  • Stop Smoking Questionnaire

  • The following questionnaire is entirely confidential. The questions and answers within are for the sole purpose of aiding us to assess how to proceed with your sessions.  Because the practitioner needs to be aware of all existing and pre-existing physical and/or psychological conditions, please fill out this form completely and disclose all pertinent information.

  • Confirm Your Contact Details

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  • Share Some Personal Details

  • Date of Birth
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  • Sex

  • All sessions can be done either in person or online.  Our preferred application is Zoom but we can also connect with you on Facetime or Messenger.

    You will have to have access to this technology for online sessions.  A laptop or tablet work the best for a session since you will have to be relaxed and not holding your device.  We will need to see your face and your arms during a session.  If you can sit in a comfortable flat backed or lounge chair, that works the best.  Please make sure you won't be interrupted during a session and that you are in a quiet enviroment.  Hypnosis takes a great amount of concentration. 

  • Do you have access to:

  • Current Mental & Health Issues

  • Do you have any of the following medical issues? Please check all that apply
  • Do you have any hearing problems?
  • Are you afraid of or uncomfortable thinking about any of the following?
  • Have any members of your family every suffered from alcohol or drug addiction?
  • Have you ever been in an abusive physical or emotional relationship?
  • Do you usually feel drained at the end of the day?
  • How do you handle speaking your truth to someone?

  • Smoking History

  • Do you use smoking as a form of stress relief from your job or lifestyle in general?

  • Smoking History

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  • Smoking History

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  • Smoking History

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  • Current Issues

  • Are you currently suffering from any of the following

  • Past Experiences

  • Have you ever been Hypnotized before?

  • Stop Smoking Agreement

  • This agreement will be discussed with you during your first session but it must be agreed upon by you to show that you are genuinely committed to this process and are willing to do your part.

    GOAL STATEMENT:  I will become a non-smoker by ________________________ (we will fill this date out during your first session)

    PRIMARY OBJECTIVE:  (what are my thoughts?):  I'll rid myself of the idea that I get pleasure from cigarettes or that I need to have them.  I believe I own my habit instead of the habit owning me.  

  • Do you agree with this statement?

  • ENABLING OBJECTIVES (what is my behaviour?)

  • 1. I agree to buy a different brand of cigarettes every morning (I can only buy cigarettes in the morning)
  • 2. Depending on the amount I smoke daily, I agree to reduce my daily intake by10%. The cigarettes I don't smoke I will break up and throw away before I go to sleep.
  • For vaping, I agree to calculate the number of minutes I vape per day and cut back by 10%.
  • 3. Grubbing (or bumming) a cigarette or giving any out is not permitted.
  • 4. I agree to replace my ashtrays at work and at home with a glass of water.
  • 5. Each time I want a cigarette or to vape, I will take a sip of water and ask myself "Do I really want this cigarette?" This is my trigger point. It's my signal to make me aware that I am about to become a non-smoker.
  • 6. I will practice my self-hypnosis and autosuggestion exercises every day to reinforce my goal statement.
  • 7. I will mark my calandars with a large QD on my established Quitting Day. I feel very good about this commitment.
  • 8. I will increase my intake of water and fruit during this period and take Vitamin C (note: reducing your coffee and alcohol intake will also be helpful)

  • Read and Agree to Terms

  • Hypnosis is not a substitute for allopathic, medical or psychotherapeutic treatment.  The hypnosis practitioner, therefore, does not diagnose allopathic, medical or psychological conditions, nor prescribe medical treatments or pharmaceuticals.

    Hypnosis takes a holistic approach to the client's well-being by encouraging the client to live a better and happier life of greater welll-being.  Its goal is to promote and maintain optimum health and is often effective for specific problematic issues.

    I confirm that all the information that I have given on this form is correct and that I have not omitted any key health condition that may impact or interfere with my hypnosis sessions.  I am open and receptive to the process of hypnosis and I am willing to do my part.  I will in no way hold Twin Flame Creations Inc. or any practitioner therein responsible for any unwanted side effects caused by my hypnosis sessions and take sole responsibility for my well-being.

    I also understand that 48 hours notice must be given to cancel or reschedule any appointment or I will be charged for the missed appointment..

  • Payment Information

    You can pay for your sessions by going to our website at www.awakeningangels.ca and use a credit or debit card through PayPal in our store.  We also accept e-transfers and credit cards over the phone.  Please specify your payment choice and we will contact you directly for e-transers and over the phone payment.

  • My payment choice is

  • Protection of personal information in the private sector (Bill 68)

    You have given us personal information.  We shall consider that you consent to our keeping in a file, all information you have already given or may give us, orally, in writing or electronic.  This information will not be shared with anyone else and when disposed of will be shredded.

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