Quit Smoking or Vaping
We can't change behavior unless we change the meaning we attach to it.These questions help me understand the habits and beliefs you have around smoking or vaping. I want to make your hypnosis completely personal for you, and your reasons, and your beliefs, so get really honest.
Name
First Name
Last Name
Email
example@example.com
Phone Number with Country Code
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Contact Method (Email / WhatsApp / Facebook Messenger / Other)
Relationship status
Occupation
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number (with country code)
Please enter a valid phone number.
Format: (000) 000-0000.
Doctor's Name and Address
Date (month & year) of last check up
Health Problems (relevant past and current)
Medications being taken
Have you been hypnotised before?
About Your Smoking or Vaping
When did you start? How long have you been smoking or vaping?
How many cigarettes or vape sessions per day, roughly?
Who's the main reason you're quitting now?
Myself
My partner
My kids
My health
Other
When do you crave a cigarette or vape most?
Morning
Afternoon
During work breaks
Before bed
Other
If you ticked 'other', please explain when you most crave a cigarette/vape.
Have you ever managed to quit before? If so, what's the longest stretch you went without smoking or vaping?
How would you rate your current stress or anxiety levels — Work
How would you rate your current stress or anxiety levels — Personal
For each of these, rate how big a part it plays in your smoking or vaping (1 = not really a factor, 10 = huge part of it)
Stress relief
Boredom
Habits/taste
Social situations
Weight
What's the biggest challenge you expect in quitting?
What's the outcome that would make this completely worth it for you? What is the image or feeling you have in mind as a result of a successful session?
How committed and motivated are you to quit right now? 10=Absolutely committed
Mental Leap Hypnotherapy is unable to provide sessions for people with epilepsy, schizophrenia, psychosis, or who are diagosed and on medication for bi-polar disorder. By ticking this box you acknowledge that you do not have any of these conditions.
I acknowledge
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