The Therapy Place
Non-Smoker for Life Hypnosis Questionnaire
Name: __________________________________ Date:_________________
Please circle or fill in the answer that applies to you:
How many cigarettes do you smoke in an average day:
1-5 6-10 10-15 16-20 20-30 30+
Where do you smoke most of your cigarettes? _______________________________
When you smoke are you alone or with others? ______________________________
Do you live with anyone who smokes? YES NO
Do any of your work colleagues smoke? YES NO
Do you smoke at work? YES NO
Have you stopped smoking before? YES NO
If yes, how long did you stop for? ____________________________
What method did you use? Patches Gum willpower hypnosis medication Other
What prompted you to start smoking again? ______________________________
What emotions do you associate with the reason you started smoking? I.e. Guilt, comfort, punishment,
contentment, stress, peer-pressure etc.
Where and when do you have the first cigarette of the day?
Do you smoke after meals? YES NO
Do you smoke in social situations? YES NO
Do you have any major stress in your life at the present time? YES NO
If yes, please describe: ______________________________________________
Do you suffer from breathing difficulties? YES NO
Do you suffer from frequent coughs, colds and flu? YES NO
Are you health conscious? YES NO
Would you describe your health as: Excellent Good Fair Poor
Has a member of your family died from a smoking related illness? YES NO
What benefit does smoking provide you?
Why do you want to be a non-smoker for life? _________________________________
How much money do you spend on cigarettes a week? ________X 52 =_________/year
What are some things you would like to do with this money?
What do you see as the benefits of being a non-smoker for life?
Name 5 things you would like to do more of or try for the first time.
My signature below indicates my commitment to myself to be a non-smoker for life through the use of hypnosis to
tap into my own powerful inner strength. I also agree to listen to the reinforcement CD daily to maintain my
My life as a non-smoker begins on ________________
If you are filling out this questionnaire outside of the office you can mail to
The Therapy Place
Attn: Gretchen Laporta LCSW
Electronically send to GretchenLCSW@Yahoo.com