Stopping Smoking Questionnaire

Start to stop now! Complete this questionnaire.

Your responses to the following questions will enable Diana to construct an effective program to help you to quit smoking.  All information you supply is kept private and confidential.

Name
Email
Phone
New or Returning Client?


Thank you for completing your responses to the questions. This will enable Diana to construct an effective program to help you to quit smoking.  All information is kept private and confidential.

Please now press the Submit button to complete this Stopping Smoking Questionnaire.



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