StopSmokingSpecialist

First & Last Name

Full mailing address, including postal code.

Cell Phone Number

Secondary Phone Number (optional)

To better get acquainted, what kind of work do you do?

Your Primary Email Address

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

Please check what applies to you.

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)

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 high, precisely because we custom tailor the sessions to you.

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
Other

How many cigarettes do you smoke daily?

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

Do you live with someone who smokes?

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 daily
I drink weekends
I drink on rare occasions - special occassions.

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.

Your coffee consumption

Never or rarely drink coffee
1 or 2 cups a day
3 or more 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.

I smoke...

Inside my home
In my car
At private social gatherings

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

Your home life is...

High stress
Medium stress
Low stress

Your daily water consumption (500 ml water bottles)

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

How many colas do you drink daily?

None or seldom.
1 or 2
3+

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

Why are you quitting smoking now?

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.

I'm under the care of a licensed mental health professional.

Yes
No

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

Please click 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.

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