Kathie Brodie, The Baggage Handler

“I can help you lose your baggage without going to the airport”
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Stop Smoking Questionnaire

Do you realize that if you smoke a pack of cigarettes a day, you are choosing to literally torch at least $250 dollar a month on a life-threatening addiction? And you think you can’t afford to quit? Are you tired of throwing your money away, smelling bad, burning holes in things and generally being an obnoxious friend by disappearing and “secretly” polluting the air? The only people that want you to think it is hard to quit smoking are the tobacco companies. Out of all the different programs and tools, compared to nicotine replacement at about 27% success and behavioral therapy at about 24%, HYPNOSIS is statistically one of the best tools to quit smoking, with a recorded success rate of 94 to 97%. Mark Twain once said, “I can QUIT SMOKING any time I want… I have done it a thousand times.”

If you have ever tried to quit and gone back to smoking, you know what it looks like to fail. Let’s change that scenario to knowing what it looks like and feels like to quit once and for all and be a success – no crabbiness, no withdrawal symptoms and no weight gain! You CAN quit smoking, and I can help you. In fact, I love to help people quit smoking so they can take control back from some stupid white paper filled with ground up leaves.

Please take some time and be thoughtful about your answers when completing this form. I look forward to our no obligation phone visit. The phone consultation will be your opportunity to ask me any questions that you may have. Also, it will be my opportunity to ask you any further questions so that I may better know how to serve you. Please have any questions ready so that we can make the most of our time together. If appropriate, we will set the time for your appointment during the phone visit.

If you want to consult before you complete the form, call me at 206-353-2178.

I am excited about speaking with you.

Download the Smoking Diary

Download Client Bill of Rights form

Today's Date

Your Name

Your Email Address

Street Address

City, State, Zip

Phone numbers

What is the best way and time to contact you?

When do you smoke?

Why do you smoke?

Where do you smoke?

Who do you smoke with?

What causes you to smoke?

When are your favorite times to smoke?

Which cigarettes do you really enjoy?

Where don't you smoke?

Who do you not smoke around?

Make a list of why you want to stop smoking

How many cigarettes do you smoke per day and what does this cost?

How many cigarettes do you smoke per month and what does this cost?

How many cigarettes do you smoke per year and what does this cost?

When do you use the logical part of your mind to make decisions?

How much do you enjoy having someone else
control you? (0-100%)

How much do you enjoy being in control of your own life? (0-100%)

How long does it take you to smoke a cigarette?

How long have you been smoking?

Have you ever tried to stop before?

Yes No

How did it go?

What seems to have induced you to start again?

What times of the day do you smoke the most?

Are there any especially challenging times?

How many cigarettes do you smoke per day?

Are you around other smokers?

Yes No

If yes, when and where?

Do you live with any smokers?

Yes No

If so, will they support you?

Yes No

What are your reasons for wanting to stop?

On a scale of 1-10, with ten being greatest, how much do you want to stop?

What would you like to do instead of smoke?

Without thinking about it, please finish this sentence: "I don't want to stop smoking
because..." (give as many reasons as possible)

Do you have any particular spiritual path?

Yes No

If so, how can it help assist you in being a non-smoker?

Describe yourself and your life as if you are already a non-smoker

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By emailing or mailing this back before your appointment, I will review it and have a plan of action to discuss with you. If it isn’t possible to return it before your appointment, we will go over the form at the beginning of your appointment. We can then determine whether you want to quit in one appointment or taper off in several appointments. The choice is yours.

I’m really pleased that you are ready to quit smoking. It will be the best gift you can ever give yourself, because you are giving it not only to you, but to your family and friends also! And don't forget your pets - they breathe the same air you do. Everyone around you benefits!

	Contact Kathie at Kathie@TheBaggageHandler.com Certified Hypnotherapist Inverse Wave Therapy Practitioner Metaphysician and Lightworker Level III Certified Reconnective Healer Reconnective Healer for Pets Reiki Master Author 18505 Firlands Way N, Shoreline, WA 98133 (located inside the Shoreline Community Acupuncture facility) Phone: 206-353-2178 • Fax: 206-546-1164