Name *

First Name

Last Name

I have not been pressured or coerced into STOPPING MY NICOTINE HABIT by a doctor or loved one *

Agree

Not Agree

I am completing this program by my own choice *

Agree

Not Agree

I have cleaned all areas that I have smoked/vaped/chewed – vehicle, home, office, outdoor area *

Agree

Not Agree

I have cleaned / given away / thrown away all of my ashtrays / butt containers *

Agree

Not Agree

I have gathered all my cigarettes/vape devices/tins of tobacco & lighters and am ready to throw them away after I listen to the stop smoking hypnosis session. *

Agree

Not Agree

I have turned off all distractions: phone(s), TV, Radio and background noises *

Agree

Not Agree

I have ensured that I will NOT be disturbed for the next 60 mins *

Agree

Not Agree

I agree that I am responsible for my own success. *

Agree

Not Agree