Tobacco Cessation Enrollment Form

Thank you for your interest in QHS’ Tobacco Cessation program. This program is designed to support everyone who has thought about quitting tobacco, even if you are not ready to begin. If you are ready to quit, health coaching combined with Nicotine Replacement Therapy (NRT) gives you the best chance of quitting tobacco for good. Fill out this form to enroll and a health coach will reach out to you to schedule your first session.

Name

Company Name

Phone you prefer to be contacted on

Best time of day to contact you

Which statement describes you best right now?

I am not intending to quit tobacco in the next 6 months

I am intending to quit tobacco in the next 6 months

I am ready to quit tobacco in the next 30 days

I quit tobacco less than 6 months ago

I quit tobacco more than 6 months ago

On average, how many cigarettes do you smoke per day?

1-5

6-10

11-15

16-20

More than 20

How soon after you wake up do you smoke your first cigarette?

Less than 30 minutes

30-90 minutes

More than 90 minutes