Sierra Center for Peak Perfromance

STEP I:
PERSONALIZED
STOP SMOKING ASSESSMENT

Please use this form to identify your reasons for breaking your nicotine addiction and Dr. Relax will turn your reasons into powerful affirmations, mental rehearsals and relaxation training that will motivate, inspire and reinforce your efforts to stop smoking. 

To take the first step in the development of a personalized stop smoking program that is specific to you, your reasons for quitting and your unique circumstances, simply complete this form and click on "Send" at the bottom. 

You will receive a confirmation of your successful submission or an error message that will tell you what you missed. If you receive the error message just hit "Back" in your browser, correct the error and hit "Submit" again at the bottom of the page.

What is your first name?
What is your last name?
What is your gender?
What is your age?
How long have you smoked?
What is your "Quite Date"?
What medication (nicotine gum, etc) will you use?
What are your 10 reasons for quitting?

1.
2.
3.
4.
5.

6.
7.
8.
9.
10.
What is the single biggest challenge to you quitting?
What feelings or emotions will you have when you have quite for good? (Try to name more than four if you can.) 1.
2.
3.
4.
5.
What specifically do you believe my CDs and training will help you to improve?
Name three people you admire. 1.
2.
3.
Daytime Phone
Evening Phone
E-Mail address to receive your draft affirmations


    Confirm E-mail Address Below
Privacy Statement