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 ________________

Signature:_________________________________                Date:___________

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