Smoke Freedom Registration Form

Please fill out this form as best you can, and submit your Registration Application. By submitting this application you are under no obligations. This will allow our staff information about you before we contact you set up your appointment, for a smoke-free future.

Form Submission

SmokeFreedom is based in the Portland, Oregon/Vancouver, Washington area (but does occasionally travel outside our area). We offer corporations a chance to stop smoking-related illnesses from employees, costing their company losses based on these illness. We offer individuals and groups (up to 40 per group) the chance to be finally be free of smoking without the awful withdrawal, without the hunger, without the pain and without having to wait for weeks until a patch or gum can take effect, (and usually at lower cost). All it takes is 90 minutes. 90 simple minutes to finally be free of this costly and nasty burden. Once this form is submitted it will be evaluated by our staff.

User Information

Date:
Age:

First Name:
Last Name:
E-Mail Address:
Address:
City:
State:
Zip:
Home phone:
Work phone:

How long have you smoked?
How many packs per day?
What time of day?	(morning_,afternoon, evening, or throughout the day)

Why do you want to become a non-smoker?

Have you ever stopped before?
For how long?
The longest period you have been free from tobacco?

Why did you start again?

What do you fear when you stop?
Why do you think hypnosis will help you?
Have you ever tried any other programs for smoking?
(please list)
Do you have a problem or have you ever had a problem with other Addictive drugs (alcohol, marijuana, etc.)?
If "yes"please specify

Occupation:
Is you job stressful?

Employed by:

Referred by (individual):
newspaper
phone book
other

Do you have any medical problems related to smoking?

Specify:

Do you have any of the following?

Headaches		Dizziness
Hypoglycemia		Weight Problem
Epilepsy		Muscle Pain
Insomnia

IN ORDER TO UNDERSTAND WHY YOU SMOKE AND HOW SMOKING AFFECTS YOU, PLEASE ANSWER THE FOLLOWING QUESTIONS:

Is it extremely difficult for you to go half-day without smoking?
Do you have intense recurring hunger for cigarettes?
Do you feel a need to smoke a certain minimal number of cigarettes each day?
Do you often find yourself smoking a cigarette when you weren't aware of lighting one up?
Do you link your smoking with other behaviors, like drinking coffee and smoking, or talking on the telephone and smoking?
Do you sometimes go a whole day without smoking?
Do you smoke more after having an argument with someone?
Is smoking one of your most important pleasures in life.
Does the thought of never again smoking make you feel unhappy?

Most smokers do feel a little unsure about becoming a non-smoker. They want to, but they also want to go on smoking forever. The important fact for you to know about the unsure feeling you may have Is that it is not necessary to get rid of the desire to smoke totally before you stop. Often the desire to smoke will only go away after one has become a non-smoker. What is important is to know that you want to stop smoking more than you want to continue smoking. By checking the appropriate answers on the list below you will be able to assess and strengthen your own motivation to become a non-smoker.

Be as honest and thorough as possible in checking these two lists. Take your time in thinking about your reasons for wanting to become a non-smoker and your reasons for wanting to continue smoking. Be fair to both sides of the issue.

Please read both lists (below) before answering either one. Then number the list of items in each of the 2 categories--list the items in order of importance to you (please only use each number once-on each list) Use the number 0 if the statement does NOT apply to you.

WHY I WANT TO BECOME A NON-SMOKER

Please Number the items on this list between 1 & 14 in order of importance to you. Please use numbers only once. Use the number 0 if the statement does not apply to you.

To take back control of my life from nicotine.
So I can stop being embarrassed about having this habit.
To avoid the health risk from smoking.
So that I can look healthier and smell cleaner.
In consideration of my family and their health.
As a better example to my children.
To be able to breath easier and not be short of breath when I exert myself.
So that I can enjoy non-smoking activities.
To be able to taste and smell better.
So that l can be more productive at work.
To improve my financial situation by not buying cigarette.
I'm tired of burning holes in clothes, furniture, etc.
So that I can sit in non-smoking areas.
Other

Name Other Reasons Here

WHY I WANT TO CONTINUE SMOKING

Please Number the items on this list between 1 & 8 in order of importance to you. Please use numbers only once. Use the number 0 if the statement does not apply to you

It relaxes me.
I need to have something to do with my hands.
It helps me to concentrate.
It’s the something I do for myself.
I don’t like anyone telling me what to do.
I just enjoy smoking.
It keeps me from gaining weight.
Other:

(Please Name your *other* reasons here)

If there is any other information that you feel may be of help to the therapist, please explain.

Form Submission

How would you like us to contact you via e-mail
or Post Office mail
or by phone

Did you fill out the email address, your mail address and your phone number above so we may use it to contact you?

Please note all submitted forms become the property of Smokefreedom.net.

All of us here at SmokeFreedom would like to thank you for stopping by, Please submit this registration form and we shall contact you ASAP.

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