Stopping The Tobacco Habit - New Client Intake Form

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

First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
Address 1:
Postal Code:


What is your date of birth?


50 characters left.

Unfortunately I cannot schedule on line. You must call during normal business hours.

Also, 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 tobocco-free permanently.

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


How much chewing tobacco do you usually use weekly?  

7 cans +
5-6 cans
3-4 cans
1-2 cans
a can
less than 1 can
  • Comment:

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Please rank your reasons for wanting to become tobacco-free.   

(1 = Most Important)
Immediate health (diagnosed with cancer cheek, stomach, heart, gum problems)
Long-term health (avoid cancer, heart disease, gum, woh problems)
Inconvenience (having to buy them)
Social pressure (wife, girlfriend, husband, children, etc)
Social stigma (tired of being looked down on)
Tired of being a slave to it - want to prove I can
Hate the breathe, taste in my mouth
Just sick and tired of them
Other (please describe in comment section)
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Did you ever quit for longer than a week? If so, for how long? When was that?


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

Nicotine gum (Nicorette)
Zyban or Wellbutrin
Hypnosis (individual)
Hypnosis (group)
Cold turkey
To win a bet
  • Comment:

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Do you also smoke cigarettes or cigars (if so please describe your usage including quantity smoked)?

  • Comment:

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


Not sure
  • Comment:

  • 500 characters left.


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



My home (inside)
My home (outside on deck or in yard)
At work (inside or outside)
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
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Why do you use tobacco (check all that apply)?


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

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.
  • Comment:

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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  
Afraid I will becme depressed  
Affraid I can't  
Driving, working  
Other (please describe in comments section)  
  • Comment:

  • 500 characters left.

What do you know or believe about tobacco use?


 Agree Not sure Disagree   
Tobacco is addictive   
Tobacco use causes cancer   
Tobacco use causes heart disease   
Tobacco is addictive than heroin or crack cocaine   
Chewing tobacco is better for you than smoking   
Once I stop using topbacco after a month or so I can go back to using just alittle safely   
Tobacco use is attractive to the opposite sex   
I can safely smoke an occasional cigar after quitting dip   
The times I tried to quit in the past are helpful. I am ready to apply that knowledge   
  • Comment:

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 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
  • Comment:

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 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 tobacco use (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 or dip users.
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.
  • Comment:

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 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.
Read your book
Google, yahoo, MSN or other search.
Liked what I read on your website.
Local health publication newspaper ad or article.
Craigslist advertisement.
  • Comment:

  • 500 characters left.