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Omaha & Lincoln Hypnosis
Stop Smoking Intake Form

Your Success is our #1 priority.
Your success begins by filling out this questionnaire as completely as possible.

Please fill out all the information

Have you been hypnotized before?

Is your smoking making you physically uncomfortable? Explain:

Are you embarrassed by your need for a cigarette?

Do you feel your smoking controls you?

Is successfully quitting smoking a top priority?

Did you know hypnosis is 100% safe?

Do other family members smoke?

Does your family support your stop-smoking efforts?

If you have pressed the “Submit” button and nothing happened please scroll up the screen and find the Red Box of Required information.