100%

City of Berkeley Quit Smoking Intake Questions Winter 2022 Session Information. You are strongly encouraged to attend all eight sessions in a cycle. Those that complete the classes are eligible for a $25 gift card. 
Winter 2022 Session Dates - January: 13, 20, 27 February: 3, (*7), 10, 17, & 24
*Classes are on Thursdays except for Monday 2/7/2022 Time: 6-8pm

Personal Information

Contact Information
Emergency Contact Information
The Clinics are for 2 hours in a group setting that is a combination of interactive participation and lecture. Will you feel comfortable participating in this kind of environment? 
General Information

How did you hear about our quit classes? 
What motivated you to sign up for our Quit Smoking Clinic?
Have you considered or are you currently using nicotine replacement therapies?
 If so, which ones? If no please skip to the next question.
Have you ever been treated for anxiety, depression, or other mental health conditions? 
If Yes please mark all that apply below. If no then please choose N/A.
Is there anything else you would like to add that would best help us support you in preparing to be smoke free?
Our program contacts participants 30-90 days after the last session to ask if they are continuing their tobacco free lifestyle. We will also offer tobacco recovery information and referral as needed.
Powered by SurveyAnalytics