One Day Learn to Quit Smoking Intensive

During this one day seminar you will have an opportunity to understand the difference between wanting to quit smoking and being ready to quit smoking. You will learn to shift yourself towards wanting to quit AND being prepared to quit. You will leave the seminar with tools and strategies for increasing your motivation to quit and will have a plan in place.

The seminar draws on the following modalities:

hypnosis/hypnotherapy
social work
neuro linguistic programming
solution focused coaching

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Home Phone*
Home Phone*

Occupation?*
Occupation?*

Age? (minimum 18)*
Age? (minimum 18)*

Past services/products used? *
Past services/products used? *

	Medication
	Patch
	Gum
	Accupuncture
	Hypnosis
	Cold turkey
	Weaning
	Therapy

Approximately how much are you smoking now?*
Approximately how much are you smoking now?*

	Pack a week or less
	Half a pack a day
	Pack a day
	More then a pack a day

Number of times you have quit?*
Number of times you have quit?*

	0
	1-2
	3-4
	5 or more

What is the longest length of a quit?*
What is the longest length of a quit?*

	Hours
	Days
	Weeks
	Months
	1 Year
	1-2 Years
	2 or more years

How did you learn about this seminar?*
How did you learn about this seminar?*

Informed consent*
Informed consent*

	Yes
	No