Hypnosis Expert Survey

1

1 - How do you describe your cocaine usage?* This field is required.

Irregular

Weekender

Three or four times a week or more/Binger

2

2 - How often do you think about using cocaine?* This field is required.

Never

Rarely

Frequently

3

3 - How strong is your urge to use cocaine when you think about it?* This field is required.

Almost nothing

Fairly strong

Very strong

4

4 - What quantity of cocaine do you typically consume in one session?* This field is required.

Less than 0.5 grams

0.5-2 grams

More than 3 grams

5

5 - To what extent has cocaine use affected your life?* This field is required.

No problems

Some minor issues

Significant problems

6

6 - Have you attempted to reduce or stop your cocaine use?* This field is required.

Never tried to cut down

Tried and succeeded

Tried but failed

7

7 - Has your tolerance to cocaine changed over time?* This field is required.

No change

Slight increase

Significant increase

8

8 - How often do you engage in extended cocaine use sessions?* This field is required.

Never

Rarely

Frequently

9

9 - Do you use cocaine on the weekends?* This field is required.

Never

Often

Always

10

10 - How has cocaine use impacted your financial situation?* This field is required.

No impact

Some difficulties

Significant problems

11

11 - How much money do you spend average per month?* This field is required.

£100, euro 120, A$200, $130

£400, euro 480, A$800, $520

More than £1,000, euro 1,200, A$2000, $1,300

12

On a scale of 1-10 (10 being you really want to stop & 1 means you don’t want to stop at all), what number do you represent?* This field is required.

13

Name* This field is required.

First Name

Last Name

14

Email* This field is required.

example@example.com

15

Mobile Number* This field is required.

Area Code

Phone Number

16

Your Country* This field is required.

17

Calculation

18

Disclaimer: This questionnaire is designed as a preliminary screening tool only. A comprehensive assessment by a healthcare professional or addiction specialist is necessary for an accurate diagnosis and appropriate treatment plan.