Austin Hypnotherapy Solutions Stop Smoking Assessment Stop Smoking AssessmentFirst NameLast NameEmailDate of BirthDate / TimeHow long have you been a smoker? 1-5 years 5-10 years 10-20 years As long as I can rememberWhat was significant about the time that you began smoking?What significant others are smokers? Check all that apply: Spouse/Partner Child(ren) Extended family Close friends OtherPlease share the others in your life who smoke.What do you gain from smoking?How much do you smoke per day?When do you smoke? Check all that apply: First thing in the morning After meals While driving At work When consuming alcohol During stressful situations When bored When depressed OtherPlease share the other times you smoke 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.What do you think led to these attempts not being successful? Check all that apply: No willpower Easily influenced Fearful of being a non-smoker Lack of self-worth DepressionWhy do you want to quit smoking now?What will be different this time?How do you feel when you think about quitting?How will your life be different when you are a non smoker?Submit Form
