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
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.