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Confidential Stop Smoking Questionnaire

Please invest some time to complete this questionnaire. It will form the basis of your individual session with us.

Section 2: Medical History

This section concerns information that is important for our provision of high quality therapy and to fulfil our duty of care; and information disclosed herein is treated with strict confidentiality.

Are currently under the care of a medical doctor?
Are you currently under the care of a psychologis, psychiatrist, or other mental health professional?
Are you currently under the care of a naturopath or similar?
Have you ever been diagnosed with any of the following?
Do you use recreational drugs?
Has your doctor or dentist recommended that you stop smoking?
It is standard procedure for us to notify your doctor/dentist about this smoking cessation program. Is that okay?

Section 3: Getting to Know You

This section is important because it helps us to tailor your hypnotherapy session to you, personally.

Is your work stressful?
Why did you start smoking?
Do you have any previous experience with hypnotherapy?
What other methods (if any) have you used to try to stop smoking before?
What do you get from smoking?
When do you smoke?

Do you understand the following?

  • Something has to change

  • The change has to be me

  • The change has to be now

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Have you had any smoking related health problems?

Section 4: Making it Official

I am now fully and totally, 100% committed to becoming a non-smoker and to remaining a non-smoker for the rest of my life; no matter what.

Signature *

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