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Healthcare & Wellness
Smoking Cessation Program Enrollment
Baseline a quitter's habit, history, and motivation so your cessation coach starts the first session with the full picture.
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Preview · not interactiveSmoking Cessation Program Enrollment
Baseline a quitter's habit, history, and motivation so your cessation coach starts the first session with the full picture.
Your name*
Phone number*
Include your country code
Your coach will use this number — see the consent at the end.
Date of birth*
Pick a date📅
Our coaching program is for adults 18 and over.
How many years have you been smoking?*
e.g. 12
Cigarettes per day, on a typical day*
Your honest average — no judgment, it just sets the baseline.
How soon after waking is your first cigarette?
Pick a date📅
A rough estimate is fine — it is one of the strongest indicators of dependence, and it shapes your plan.
How many times have you seriously tried to quit before?
Every past attempt taught you something — your coach will build on that.
What have you tried so far?
Select…▾
Tell us what else you tried
e.g. hypnotherapy, acupuncture, a quit-smoking app
How motivated are you to quit right now?*
1 = not sure I am ready, 10 = completely committed. Anywhere on the scale is a fine place to start.
Do you have a target quit date? (optional)
Pick a date📅
Leave blank if you would rather set it together with your coach.
How would you like to be supported?*
Select…▾
Staying in touch*
Staying in touch
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