Free Assessment

If you would like a free assessment to check whether we can help you quit smoking in 60 minutes, please complete the following assessment form

First Name      

Last Name       

City / Town         

 State                  

 Email                  

Why do you think you haven't been able to quit up until now?

What are your reasons for why you want to quit smoking?

Do you want to quit smoking or are you doing it because someone else wants you to quit?

Additionally, please note any concerns you have about quitting smoking and any questions / concerns you may have about the Quit Smoking in 60 Minutes system

What are the best times for us to contact you?

What is the best number for us to contact you on?

How did you hear about us?  

If you were referred to us by someone, please enter their name below

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