Stop Smoking Intake Form

MM slash DD slash YYYY
MM slash DD slash YYYY
What are your three most resourceful personal strengths or characteristics?(Required)
On a scale of 1-10 with 1 being little and 10 being massive, how badly do you want to quit?(Required)
Who is paying for these sessions?
Do you understand that this process still requires work and dedication on your end? Specifically, not only are you desiring to quit, but you also know you need to do everything on your end to be successful, including discarding off all cigarettes or vaping devices, ashtrays, and to change up your "nest" which are the locations you would previously smoke.(Required)