Soul Glow WellBeing, Quit Smoking with Hypnotherapy - Intake Form
Holistic Healing Support Provided by Becca Briley, Ordained SoulWorker, Master Life Coach & Hypnotherapist
Email *
Blessings on your journey to empowered wellbeing by making the choice to quit smoking once and for all! I welcome you to work with me 1:1 by filling out this form in all honesty. This is confidential and a non-judgmental support.
Full Name *
Brithdate *
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How old were you when you started smoking / chewing / dipping? (Be as specific as possible) *
How often do you use tobacco? *
What have you done to stop using tobacco in the past?
What has been the longest period of time you were tobacco free? *
Why do you want to quit, and for whom are you doing it? *
Do you WANT to quit using tobacco? *
Can you see yourself as being tobacco free? *
How will your life be different when you are tobacco free? *
What is your biggest fear about quitting the tobacco habit? *
Do you have any unrelated fears that you need to inform me of? Ex: Fear of elevators (This will help me to formulate mindful scripts for your success) *
Do you prefer the beach or mountains? *
What brand of tobacco do you use? *
What are some of your habits related to your tobacco use? (Be as specific as possible) *
Do you have children, if so how do you feel about them using tobacco?
Why did you start using tobacco? *
Do you live with other users of tobacco? *
Do you know of anyone who has quit? What happened? *
What do you intend to gain from us working together? Please set an Intention. (You are planting a seed for manifestation here) *
Do you understand that this will be self-funded, holistic support? *
What is the service package agreement that you choose moving forward? (This will be based on your seriousness to quit and how quickly change shows) *
Do you prefer in person or virtual sessions? *
Required
Please make payment prior to each session. *
Required
If you are working with a primary care physician or mental healthcare specialist who you need to consult with before working with Becca, have you done so? *
Do you agree to receiving confidential, self-healing support provided by Becca Briley, Ordained SoulWorker, Life Coach, Nutrition Specialist, Reiki Practitioner, Mindfulness Mentor & Hypnotherapy Practitioner? (Becca is not a licensed therapist, counselor, psychologist or psychiatrist.) *
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