Smoking Cessation Consultation Form

1) How many cigarettes do you smoke per day? (On average for the last 6 months)

2) How many years have you been smoking?

3-a) List ways you tired to quit smoking (Hypnotherapy, Acupuncture, EFT, etc..).

3-b) Explain how effective they were.

Ex. I tried Acupuncture, it worked for a while, but I ended up smoking again.

4) How Experienced are you with Energy Work?

Very Experienced (I'm able to sense energy really well)Somewhat Experienced (I sometimes Receive Energy Work, I can somewhat feel energy)Never (I never Received Energy Work Before, I can't feel energy)

Desribe your experience with healthy living practices related to CHI/Energy such as Tai Chi, Yoga, QiGong, Reiki, Martial Arts, EFT, etc...

5) What is your stress level of your Career?

HighMediumLow

List specific issues causing you stress and that you want to work on.

6) What is your stress level with Relationships (Marriage, Dating)?

HighMediumLow

List specific issues causing you stress and that you want to work on.

7) What is your stress level with Heath?

HighMediumLow

List specific issues causing you stress and that you want to work on.

8) What is your stress level toward Aging and Beauty?

HighMediumLow

List specific issues causing you this stress and what you want to improve.

9) What is the stress level with Family?

HighMediumLow

List specific issues causing you stress and that you want to work on.