Stop Smoking Client Intake Form — GROSSMAN HYPNOSIS METHOD

New Client Stop Smoking Intake

Please answer the questions to the best of your ability. This confidential information that you provide will allow Dr. Kenneth Grossman to customize your session to your lifestyle.

NOTE: If you chew tobacco, smoke cigars or a pipe, or vape please answer accordingly.

Client Name

First Name

Last Name

Date of Birth

YYYY

Age

Name of Parent or Guardian if Under 18

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Home Phone

(###)

###

####

Marital Status

Please list any specific health problems you are currently experiencing.

Are you currently employed?

Yes

Retired

If yes, what is your current employment situation?

How many cigarettes do you smoke per day?

Which brand of cigarettes do you smoke?

What is your estimated cost of smoking per year?

How old were you when you started smoking?

When you were a child did your father smoke?

When you were a child did your mother smoke?

Have you tried to stop smoking in the past?

Which method have you tried?

Has any method been successful? If so, for how long?

Are there any special concerns that make you want to stop smoking NOW?

Is there anything else you wish to share?

How did you hear about us?

Client signature or signature of Parent or Guardian if under 18.

Use your finger or mouse to sign below.

Date

YYYY