Quit smoking 1:1 - FORM

Before starting our journey together, please fill out this form. You can express yourself as much as you need.
What you write in this form remains strictly confidential.

I will personally review it and email you back if I have any questions. By filling our this form you have the opportunity to brainstorm your reasons for wanting to quit smoking and what else may make you struggle.

Thank you.

1. Name (please include all names) *

First

Middle

Last

2. Best phone to reach you

To contact you in case I need. I won't use it for anything else.

3. Best email address to get in touch *

4. Your address ( I need it only to make the invoice) *

4. Occupation

5. What is your primary reason/goal for your sessions with me? *

6. Please list the benefits that you expect to gain from our sessions. *

For example, if your goal is to quit smoking, some benefits might be: "I want to feel healthier", "I want to save money", ...

7. Please list the 3 most important concerns regarding this issue, in order of importance. *

For example, if your goal is to quit smoking, some benefits might be: "I want to feel healthier." or "I want to safe money".

8. Have you made any previous attempt to address this issue? *

If "Yes", what did you do and what were the results?

9. How long have you bee a smoker? *

1-5 years
5-10 years
10-20 years
As long as I can remember

10. What was significant about the time that you began smoking? *

11. What significant others are smokers? *

Partner
Children
Extended family
Close friends
Colleagues
Other
None

You may tick more than one

12. What do you gain from smoking? *

13. How much do you smoke per day? *

14. When do you smoke? *

First thing in the morning
After meals
While driving
At work
When consuming alcohol
When talking on the phone
During stressful situations
When bored
Other

Tick all that apply

15. Have you tried to stop smoking previously? If so, please provide details (i.e. how long did you stop and what caused you to start again) *

16. What do you think led to this/these attempt(s) not being successful? *

No willpower
Easily influenced
Fearful of being a non-smoker
Lack of self-worth
Other

You may tick more than one

17. Why do you want to quit smoking now? What will be different this time? *

18. How do you feel when you think about quitting? *

19. How will your life will be different when you're a non-smoker? *

20. Please list any other past/present significant physical/mental/emotional/spiritual challenges you feel important for me to know:

21. Do you have any relevant medical condition/s? *

If "Yes", please elaborate

Are you currently under a physician’s care for these conditions?

22. Are you currently under the care of a mental health professional? *

23. Are you taking any medication (not including vitamins and food supplements)? *

If yes, please list what they are and what they are for:

24. Do you take any drug? *

25. Have you ever being hypnotised before? *

If 'Yes", what for?

How was the experience?

26. Have you ever done other counselling, coaching or therapy before? *

If 'Yes", what for?

Did it help?

27. Do you meditate, or are you familiar with meditation? *

Yes, I meditate almost every day
Yes, I sometimes meditate
Yes, I have tried
No

28. Do you have difficulty with any of the following: *

Ability to sleep
Self-esteem
Relationships
Work
Energy level
Appetite
Other

29. What are sources of stress for you? *

30. If there is anything else you'd like to share with me, please use this space her below.

31. Where did you hear about me? *

Date *

Thank you for filling this out. Please could you type again your email address, to make sure it is correct? Thank you. *

Name

Quit smoking 1:1 - FORM

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