STOP SMOKING REGISTRATION FORM
STRICTLY CONFIDENTIAL

 
Weight Loss • Chronic Pain • Excessive Drinking • Drug Abuse • Break Ups
Phobias • Gambling • Depression • Stress • Memory Improvement
 
Please complete this registration form and choose one or more of the following:
     
 
Date:  
Name: Marital Status:
Address: City/State/Zip:
DOB: Age: Occupation:
Phones/Contact:
Home: Work: Cell: Email:
 
Have you ever seen a (check all that apply)        
If yes, please give their name(s):
Where did you hear about us? (check all that apply)      
           (specify)
How were you referred to
Dr. Smith?
Who is your physician and what is their specialty?
Physician's office location (City/State/Zip/Phone):
Do you object to us contacting him or her about your success?
Do you spend more than $100 a month on smoking?
Describe how smoking controls or interferes in your life?
Which of these fears do you have of stopping smoking? (Please check all that apply):
Do other members of your family smoke?
Do you have a smoking related illness?
Please Explain:
How many cigarettes/pack(s)
per day?
Number Years Smoking?
Circle the strongest desire to stop smoking, with 10 equaling the strongest.
List three reasons why you want to stop smoking:
  1.  
  2.  
  3.  
List three places or situations in which you smoke the most:
1.      2.      3.
What methods have you used to stop smoking before?
Did you stop?
For how long?
Do you have any of these symptoms for which short term counseling techniques may be useful? (Check all that apply)
 
For Weight Loss Only
Our unique program can quickly eliminate the cravings for unhealthy foods; reduce portions, and stops eating from stress and boredom.
 
Give three reasons why you are overweight?
1.      2.      3.
How much weight have you decided to lose?
If you successfully lost 20 lbs. or more in the past, how did you do it?
 
Questions about total cost of programs are addressed at the consultation. See more details at our Fee For Services Page. To secure your appointment for an hour evaluation for $35 which may also be applied to a therapy session, please submit the registration form and pay your evaluation fee on the next page.
Review the online video testimonials before your consultation
Please submit and bring in this form to your evaluation.
 
 
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