Oregon Hypnosis & NLP Clinic

Stop Smoking Questionaire

Oregon Hypnosis & NLP Clinic - Stop Smoking Questionnaire.

Personal Information (Will be kept confidential).
*Title:
*First Name:
*Last Name:
*E-Mail Address:

Contact Information (Will be kept confidential).
*Address1:
Address2:
*City:
*State:
*Zip:
*Phone:
*E-Mail Address:

Survey Questions (Will be kept confidential).
1. How important to you is it to stop smoking?
not very
somewhat
important
greatly
very
2. How do you feel about the results of your last stop smoking program you were on?
terrible
disappointed
ok
good
great
3. How many stop smoking programs have you been involved in?

4. I find that I smoke...
...more when I'm upset
...less when I'm upset
...about the same amount regardless how I feel
5. How did you hear about our program?

6. Any additional comments, questions you have?

	Yes, I would like more information on your program and how it can help me be a non-smoker and stay that way.
	Yes, I would like to schedule a no obligation evaluation, please have someone contact me as soon as possible.
**Fields marked with a '' are required to be filled before submitting the form.***
NOTE: We do not do evaluations over the Internet. Please include your phone number for a personal consultation.

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