Stopping The Tobacco Habit New Client Intake Form
1.

Please provide some contact information. Your information is confidential and will not be shared.


First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
City:
State/Province
(US/Canada):
Postal Code:

2.


What is your date of birth?

 

50 characters left.

Congratulations on your decision to change your life for the better by becoming a non-smoker

.

Please understand this is a three session program with hypnosis at all sessions. You will not be asked to quit at the first session but will be smoking under direction for 2-7 days between sessions. Typically, the second session is your quit day. Clients typically cut down by 50% or more between sessions one and two. The third session is a followup that is used for reinforcement, stress reduction and problem solving designed to make sure this time you become a non-smoker permanently.This is a specific protocol that produces an 85% success rate, please do not ask me to quit at the first session. This works the way it is designed.

And remember you must call to schedule your first appointment. 401.374.1890 for Warwick, RI (THE WARWICK MEDICAL CENTER, 400 BALD HILL RD, WARWICK, RI, opposite Macy's) and 508.336.4242 for Seekonk, MA (The Tree of Life Wellness Center, 1460 Fall River Ave).
 

Also understand that I am not a medical doctor or licensed psychologist, counselor, psychotherapist, dietitation, nutritionist and do not diagnose or treat any diseas

 
3.

How many cigarettes do you usually smoke daily? (Chewing tobacco clients describe your habit in the box below):

 

2 packs or more (40 cigarettes or more)
1.5 - 2 packs (30 - 40 cigarettes)
1 to 1.5 packs (20 - 30 cigarettes)
.5 to 1 pack (10-20 cigarettes)
Less than .5 packs (9 or fewer)
Other
  • Comment:

  • 500 characters left.
4.

Please rank your reasons for wanting to become a non-smoker.


(1 = Most Important)
 
Immediate health (cough, doctor's orders, shortness of breath, etc)
Long-term health (avoid cancer, heart disease, lung disease)
Cost
Inconvenience (smoking outdoors, having to buy them)
Family pressure (wife, husband, children)
Social stigma (tired of being looked down on)
Tired of being a slave to them - want to prove I can
Hate the smell
Just sick and tired of them
Other (please describe in comment section)
  • Comment:

  • 500 characters left.
5.

Did you ever quit for longer than a week? If so, for how long? When was that?

 

350 characters left.
6.


What techniques have you used to try to quit (please check all that apply)?

Patch
Nicotine gum (Nicorette)
Chantix
Zyban or Wellbutrin
Electronic Cigarette
Hypnosis (individual)
Hypnosis (group)
Prayer
Cold turkey
To win a bet
Other  
  • Comment:

  • 500 characters left.
7.

Have you ever been hypnotized? If so please briefly tell me about it in the comment section.

 

Yes
No
Not sure
Other  
  • Comment:

  • 500 characters left.
8.

 

Where/when do you smoke/use tobacco (check all that apply)? 

 

 

 
My home (inside)
My home (outside on deck or in yard)
At work (inside or outside)
Driving
Drinking alcohol
Drinking coffee
After meals
On phone
At computer
Middle of night if I wake up
First thing before breakfast
Right now while I am filling out this form
Other  
  • Comment:

  • 500 characters left.
9.

Why do you smoke/use tobacco (check all that apply)?

 

Relieve stress
Pleasure
Just a habit
Energy boost when tired
Calm down when I am agitated
Helps me think
Seems a compulsion
Other  
10.

How ready do you feel you are to quit?

Very ready. I really want this
Ready. I know I can't continue to smoke, just need some help.
Not sure. Open to quit if I can.
Not ready. Doing this because someone is urging me to. I will see what happens.
Other  
  • Comment:

  • 500 characters left.
11.

Please rate your concerns and fears about the quitting process:

 Very Major Concern Major Concern Not sure Not a Concern  
Weight gain  
Might be too difficult  
Whether I can be hypnotized  
Letting people down  
Letting myself down  
Anxiety/nervousness  
Afraid I will becme depressed  
Affraid I can't  
Driving, working  
Other (please describe in comments section)  
  • Comment:

  • 500 characters left.
12.

What do you know or believe about cigarettes/tobacco?

 

 Agree Not sure Disagree   
Cigarettes are addictive   
Cigarettes cause lung cancer   
Cigarettes cause heart disease   
50% of people who smoke their whole lives die from it   
Cigarettes are more addictive than heroin or crack cocaine   
Light cigarettes are better for you than "full-flavored" cigarettes   
Once I stop smoking after a month or so I can go back to having just a few safely   
Poisions like amonia, tolulene, arsenic are added to make cigarettes more addictive   
Lungs, heart and other organs begin to improve when I quit smoking   
The times I tried to quit in the past are helpful. I am ready to apply that knowledge   
  • Comment:

  • 500 characters left.
13.

 What advantages are important to you in becomming a non-smoker/former tobacco user (please check all that apply)? 

 
Immediate improvement in health/energy/breath
Long term health
Money saved
Feeling of freedom and confidence
Romantic (current partner or new partners)
Prove I can do it....I am not a slave to cigarettes
Time savings
Good example to my children or young family members
Keep a promise to someone
Stop being looked down on
Reduction in my insurance costs
Win a bet or show friends, family co-workers I can
Other  
  • Comment:

  • 500 characters left.
14.

Please answer the following to help me best help you achieve your goals. Check all that apply.

 

 

 

 

I have been diagnosed with a health issue related to smoking (cancer, heart disease, c.o.p.d., emphysema, bronchitis, etc).
I have a tendency to suffer from depression. But it is under control.
I am currently taking Zyban, Wellbutrin or am on the patch.
I live with a smoker or frequently socialize with one or more smokers.
I am currently in psychotherapy or under medical treatment for a mental illness.
I have ever been hospitalized for a mental illness or substance abuse issue.
I am very uncomfortable at places such as the beach, an elevator, small boat, up a ladder, in a crowd..
Aside from smoking, I am a healthy person who has achieved many things in life that seemed difficult at first.
Other  
  • Comment:

  • 500 characters left.
15.

 What made you choose me to help you quit smoking/stop using tobacco. Please check all that apply.

 

My doctor or hospital recommended you.
A friend or family member recommended you. Please provide their name in the comments section.
Heard you on the radio or saw you on television.
Heard/met me at a lecture.
AMAZON LOCAL DEAL
Google, yahoo, MSN or other search.
Liked what I read on your website.
Local health publication newspaper ad or article.
Craigslist advertisement.
Other  
  • Comment:

  • 500 characters left.