The following questionnaire may take as long as 20 minutes to complete. You cannot do some and save the rest for later. It must all be done in one sitting. Be sure you have 20 minutes available as you cannot save portions of it. Complete it in full and click submit. Thank you.


Intake form / Questionnaire (copyright protected)

Medical issues (click what applies to you)

Your SMOKING PROFILE: To assist the hypnotist in customizing your sessions for maximum results, we need as much information as possible. The more information you provide us, the better.

How many times have you tried to quit?

If you did manage to quit for awhile...