City of Berkeley Quit Smoking Intake Questions Fall 2020
Session Information 
You are strongly encouraged to attend all eight sessions in a cycle. 
Fall 2020 Session Dates - October: 8, 15, 22, 29 November: *(2), 5, 12, & 19
*Classes are on Thursdays except for Monday 11/02/2020

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

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?