StopSmokingSpecialist

First & Last Name

Full mailing address, including postal/zip code.

Cell Phone Number including area code. If outside North America, include your country code.

Secondary Phone Number (optional)

Your Primary Email Address. **We do not sell, rent of share your email address. This is strictly for private client/hypnotherapist communications.

To better get acquainted, what kind of work do you do? Your occupation can say a lot about your mindset. (Example: if you are an air traffic controller, we know you are in a high stress job).

MEDICAL INFORMATION. This confidential information is required in order to better assist you in your custom-tailored hypnosis program.

Check what applies.

I have allergies.
Diabetic.
Diagnosed heart condition.
High blood pressure.
Chronic pain.
Asthma.
Epilepsy.
Chronic headaches.
Diagnosed with anxiety disorder.
Diagnosed with depression.
Diagnosed with Attention Deficit Disorder.
Diagnosed with Bipolar.
I have a hearing problem.
I'm afraid of heights.
I'm afraid of water.
I'm afraid of enclosed spaces.
I have COPD (Emphysema)
I have attention deficit disorder (ADD)
I have PTSD
I have bipolar
I'm taking medication for my physical issues
I'm taking medication for my mental issues

Your Unique Smoking Profile. To assist the Hypnotist in customizing your sessions for maximum results, we need you to complete the following smoker’s profile. Please keep in mind, that our success rate is very high (90%), precisely because we custom tailor the sessions to you.

Check what applies. What quitting methods have you tried in the past?

Will power (cold turkey)
Nicotine patch/gum/inhaler
Laser therapy
Prescription drugs
Self-help groups
Group hypnosis
One-on-one hypnosis session(s)

How many cigarettes do you smoke daily? If you vape, how many units?

How many years have you smoked? If you quit and started several times, please elaborate.

Do you live with someone who smokes?

Areas where you smoke - Check what applies

In the home
In the car
At bars &/or restaurants
Wherever it is legally permitted

If you have breakfast, do you smoke before breakfast?

Always
Occasionally
Never

Do you smoke just before bedtime?

Always
Occasionally
Never

Do you get up at night to smoke?

Always
Occasionally
Never

ALCOHOL: Alcohol is a potent trigger to smoking. We need to know your lifestyle around alcohol. We've had clients that drank 7+ beers daily and others that drink once a year at Christmas. We are not here to judge. Your honesty is important if we are to assist you in your goal of being a non-smoker.

My alcohol consumption is as follows:

I never drink
I drink on occasion
I drink mainly weekends
I drink daily
I drink daily & it's getting out of control

When I consume alcohol

I usually smoke cigarettes with it. They go hand in hand.
I can easily drink and not smoke. They are not linked.
I don't drink

Your coffee consumption

Never or rarely drink coffee
1 or 2 cups a day
3 to 5 cups a day
6-10+ cups a day

When I drink coffee...

I always have a cigarette with it.
I often have a cigarette with it.
I seldom have a cigarette with it
I never have a cigarette with it.

Check what applies. I tend to smoke more when..

I drink alcohol
I'm under a lot of stress
I drink coffee
I'm in a social situation where smoking is permitted.

Your work life is...

High stress
Medium stress
Low stress
I'm retired

Your home life is...

High stress
Medium stress
Low stress

Your daily water consumption (500 ml / 16 ounces water bottles)

I never or rarely drink water.
1 or 2 bottles a day.
3-5 bottles a day.
6+ bottles a day

How many colas do you drink daily?

None or seldom.
1 or 2
3-5
6+

Do you meditate?

No
On occasion
Regularly

What calming and relaxing activities do you enjoy most? (Example: going for a walk, reading a novel)

Cannabis consumption

Never
Occasionally
Daily
Multiple times daily
I want to stop or reduce

Cannabis. Check what applies.

I smoke it (joints)
I vape
I add tobacco to it
I use edibles

Why are you quitting tobacco now? Check what applies.

I have a diagnosed medical condition that requires it.
I feel my health is deteriorating.
My loved ones are pushing me to quit.
I've reached a saturation point. I'm fed up with smoking.
I want to improve my finances.
I'm tired of smelling like an ashtray.
I want a better quality of life.

In hypnosis we also use aversion therapy. We can link the taste of a cigarette to your memory of very bad taste you had in your mouth. Example: rotten meat, rotten fish, liver. Something that you were repulsed by.

While in hypnosis we can create social reinforcement. Who is in your inner circle, spouse, parents, close friends, siblings, kids, grand kids or relatives that would be very happy that you quit smoking. We can give them a voice in hypnosis. Example: “Uncle Harry is very happy that you finally quit smoking”.

After you quit smoking, are there other areas you would like to work with? Check what applies.

No, not really.
Stress Reduction
Fear of public speaking
Improve my diet
Motivation for fitness
Reduce alcohol
Improve my sleep
Reduce anxiety & worry
Other (not listed here)

Please check what applies...

I was referred to you by one of your clients.
I found you online.
I read your entire website.
I scan read your website.
I did not read your website, I grabbed the number and called you.
I watched your video

Any other information that you want to share that you think might help the hypnotherapist serve you better.

Why did you choose Mike Proulx for your hypnosis needs? Please elaborate.