Your Name:

Your E-mail:

Your Phone Number:

Preferred method of communication?

E-mail

Phone

Either One

Are you certain that smoking cessation is something you want? It is not enough to "have to" quit smoking; you must "want to" quit for your own, personal reasons. So choose one:

Yes: I want to quit for my own personal reasons.

No: I'm interested in quitting only for other people; I don't really want to quit.

What are your primary reasons for quitting? (list about 5 reasons)

Of the reasons to quit, which one is the most important?

Why? Elaborate for a few sentences. Use emotional and rational reasons (i.e. for health, you might have "I want to be there for my children when I'm older; I don't want to be coughing all the time; I'm afraid of getting cancer).

What are the downsides of smoking? (i.e. clothes smell, feel lousy)

What do you hope to gain from quitting smoking?

Of the top 12 common reasons to quit smoking offered below, pick your top three:

To regain control

To save money

For children (including future children)

For health

Coughing

Breathing problems

Fear of Dying

For others

Inconvenience

Bad smell

Anti-social

Premature aging

Best time to come in for session (The session takes about 90 minutes and occurs in Beverly Hills):

Mornings

Afternoons

Evenings

Weekends

Any questions or things I should know?