Stop Smoking In Take Form Please note that all fields are required. Your Full Name Your Email Address Your Phone Number Your Birth Date How would you rate your level of stress? (0 is no stress, 10 is the worst is can be) How many cigarettes do you smoke, on average, per day? What is the longest you can go without a cigarette? Why do you believe you smoke? If you've ever tried to stop smoking please provide details about the results you achieved. What do you wish to accomplish in this/these session(s)? Please provide more information if you have ever been treated for an emotional problem. Please provide more information if you have any fears or phobias. Any additional informaton you want to add or I should know? By submitting this form you agree that Jaco Pieterse is a hypnotist and not a medical doctor or psychologist, and that he cannot diagnose disease, prescribe, or treat specific medical conditions.