Stop Smoking Form

Fully complete and submit this consent form BEFORE your session. A copy will be sent to you upon completion.

Comments
This field is for validation purposes and should be left unchanged.
First Name*
Surname*
Email Address*
What age did you first smoke?*
What were your reasons for starting smoking?*
Which brand did you prefer?*
How many a day have you been smoking?*
Have you tried to stop smoking before now?*
- Yes
- No
If YES, please give details when you stopped and for how long, what method you used and what happened to cause you to start up again?*
What is your commitment to stopping smoking? Be honest with yourself {%):*
Please enter a number from 1 to 100.
After my appointment, my commitment is (%):*
Please enter a number from 1 to 100.

List your reasons for choosing NOW to decide to stop smoking: