Quit Vaping Form

Quit Vaping Intake Form

Please fill out prior to the session
Full Name*
Phone Number*

Area CodePhone Number
E-mail Address*
Occupation*
Marital Status
Referred by:
Your age? *
Date of birth*

MonthDayYear
Date
Are under medical care?

YesNo
Are you on any medication?*
Have you ever been hypnotised?*

YESNO
If YES: What for?
If YES: By whom?
If YES: Were you happy with the results?
How long have you been vaping?*
What age did you start vaping? *
Have you ever been smoking cigarettes?*
If YES: How long have you been smoking cigarettes for?
If YES: what age did you have your first cigarette?
Have you ever stopped vaping?*

YESNO
If YES: What worked for you?
If YES: How long have you stopped vaping for?
Do you have physical symptoms? (cough etc.) *
When do you enjoy a vaping the most? *
Anyone else in your house vaping?*
Does anyone else want you to stop vaping? *
Do you consider vape a friend?*
Do you think nicotine is addictive?*

YESNO
What do you think vaping does for you that you don’t think you can do for yourself?*
Is there anything you want me to know?
Terms & Conditions

Hypnotherapy does not constitute Psychiatric treatment and is not a replacement for medical mental illness treatment or doctor’s diagnosis, care and medications. I am not currently being treated for any medical condition related to the reason I’m here or I have gained the appropriate medical approval from my GP/ healthcare practitioner.

There is a 24h Cancellation Policy and a $50 fee is applied should I cancel an appointment in less than 24h. Non-attendance without a prior warning will result in a charge being made that is equal to the fee of the session. The therapist reserves the right to reschedule a session, ensuring that the new appointment is suitable for the client.

Any materials (Mp3, pdf etc.) provided by Recall Hypnosis are for my personal use only and they are not to be lent, copied or sold under any circumstances.

All payments made for services rendered are non-refundable.
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Quit Vaping Intake Form