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| Name (what you would like me to call you) : * |
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| E-Mail Address: * |
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| Date of Birth: ( ex: 06/01/70) * |
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| City / Town where you live: |
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| State |
Country |
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| Gender: |
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Male |
Female |
Please describe the main reason you are seeking counseling and/or coaching from REFUSETOQUIT.com, including your questions, as clearly as you can:
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If you know what you would like to happen, please tell me here *:
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Have you had any type of mental health services in the past: |
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Yes |
No |
If yes, please describe when, for what and how(if) it was helpful:
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| Relationship Status:
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| Other type of relationship or special circumstances (please describe) |
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| Do you have children: |
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Yes |
No |
| If so, list gender and ages |
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Living Arrangement: how many people do you live with and what is there relationship to you: |
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| Employment Status:
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| Do you enjoy your work: |
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Yes |
No |
Somewhat |
| Type of work you do: |
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| Highest level of education received:
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| List any health problems you have: |
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| Please list any medication you take: |
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| Do you drink alcohol: |
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Yes |
No |
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| If you do, how much and when:
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| Do you use any other substances: |
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Yes |
No |
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| Other relevant information regarding substances, past or present |
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| How did you hear about REFUSETOQUIT.com |
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| Are you seriously considering suicide at this point:*(required) |
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Yes |
No |
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IF YOU ARE SERIOUSLY CONSIDERING SUICIDE, E-COUNSELING IS NOT APPROPRIATE FOR YOU RIGHT NOW. PLEASE CALL THE NATIONAL SUICIDE HOTLINE AT 1-888-248-2587, A SUICIDE HOTLINE IN YOUR AREA OR CALL 911. |
