Stop Smoking Form
Fully complete and submit this consent form BEFORE your session.
First Name
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Surname
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Email Address
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What age did you first smoke?
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What were your reasons for starting smoking?
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Which brand did you prefer?
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How many a day have you been smoking?
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Have you tried to stop smoking before now?
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Yes
No
If YES, please give details when you stopped and for how long, what method you used and what happened to cause you to start up again?
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What is your commitment to stopping smoking? Be honest with yourself {%):
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Please enter a number from 1 to 100.
After my appointment, my commitment is (%):
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Please enter a number from 1 to 100.
List your reasons for choosing NOW to decide to stop smoking:
Health (eg, short of breath, have witnessed others die because of smoking cigarettes, signs of aging caused by smoke etc)
Financial (eg, It's a waste of money, it's expensive, money could be used for other things)
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Social (eg, becoming more and more unsociable, aware of the unpleasant small on my clothes and breath)
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Family (eg, I am worried about the health of my family, children, don't want my children to copy my habit)
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Self Esteem (eg, I will feel as if I have achieved something to be proud of)
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What will it be like when you have what you really want? (Describe in detail what you would NOTICE, what would you SEE, what would you HEAR and what does it FEEL like?)
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Submit
Should be Empty: