Borders Quit Smoking Hypnotherapy

Borders Quit Smoking Hypnotherapy

Client Intake Form
Please complete and return this form no later that 48 hours before your appointment time.

The boxes will expand to your text.
Name*

First NameLast Name
Date of Birth

DayMonthYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Phone Number
Please enter a valid phone number.
Occupation
Appointment Date Arranged

DayMonthYear
Date
Please list any Medications and Health Conditions you are taking, type, reason, approval from your Doctor may be necessary prior to our hypnosis session.
Gender
Marital Status
Number of Children
Doctors Name and Phone Number
Permission to share with Doctor
Those Most Proud of you when you quit smoking.
Are you under pressure from others to quit?
Where did you find me
Cigarettes per day
What Tobacco products do you smoke. eg. packet cigarettes, rolling tobacco, cigars, vapes
Age started smoking
Enter the age you started smoking
Spend per year on smoking
£
What triggers you to have a cigarette eg. with a drink, after a meal, stress, boredom, confidence etc.
What methods have you tried in the past (if any) to stop smoking, how long did you quit for each time and why do you think they failed.
What are your main reasons for wanting to quit smoking and why now?
How does smoking help you, or what do you like about smoking?
Are there any other personal issues influencing your need to smoke.
Other areas you feel you need help with (anxiety, stress, sleep, phobias, weight loss etc)
I consent to my data being collected and stored for the purpose of the BQT programme.
All information provided remains confidential:

https://www.borders-therapies.co.uk
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