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Quit Smoking Intake Form

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About Your Contact

What is your email address?

Where did you first hear about us?

The Start Of That Old Habit

When did you start smoking?

What events were happening in your life when you started smoking?

Why did you start smoking?

About Your Old Habit

On a scale of 1 (low) to 10 (high), how much do you enjoy smoking?

What do you enjoy about smoking?

On a scale of 1 (low) to 10 (high), how much do you want to keep smoking?

On average, for the last month, how many did you smoke each day?

How much do you spend, in pounds, each day smoking?

How much do you spend, in pounds, each year smoking?

What brand do you smoke?

When do you smoke each day? (e.g. after waking up)

What triggers you to light up?

What feelings do you have before lighting up?

What feelings do you have after lighting up?

How else can you get those positive feelings?

How does smoking taste to you?

How does smoking smell to you?

What did you try doing to stop smoking before?

How well did the attempts work?

About Your Change

What other events or things about your life bother you or have been bad?

Why do you want to be a non-smoker?

On a scale of 1 (low) to 10 (high), how much do you want to stop smoking for ever?

At the times of day when you used to smoke, what will you do instead?

How clearly can you imagine a big colourful video of you not smoking?

What will your hands do when not smoking?

Who will help you become a non-smoker?

Who will hinder your becoming a non-smoker?

On a scale of 1 (low) to 10 (high), how ready are you to become a non-smoker?

What would really motivate you to become a non-smoker?

Any other comments, questions or thoughts?

FreeYourMind.UK provides advanced confidential therapy to help deal with anxiety in London, Guildford, Surrey, UK and online.