We need to receive the completed form before your first session is to begin. Please be aware that this form does not allow you to save part way and go back to finish it later. This form must be completed in one sitting. It takes approximately 10 minutes to complete. Thank you. 

Intake Form

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.

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?

If you have breakfast, do you smoke before breakfast?

Do you smoke just before bedtime?

Do you get up at night to smoke?

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:

When I consume alcohol

Your coffee consumption

When I drink coffee...

I smoke...

I tend to smoke more when..

Your work life is...

Your home life is...

Your daily water consumption (500 ml water bottles)

How many colas do you drink daily?

Do you meditate?

Cannabis consumption

Why are you quitting smoking now?

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

Please click what applies...