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PRE-QUIT SMOKING QUESTIONNAIRE

IMPORTANT: Answer the following 24 questions and email this to: This e-mail address is being protected from spambots. You need JavaScript enabled to view it. at least 48 hours prior to your coaching session.

Answering these questions save you one Coaching session and greatly assist your Coach. This will help you to move forward quickly and enable your coach to light up the neural pathways that ensure success. Please answer the following questions as honestly and specifically as you can. It is also helpful to get into a peaceful and focused state to allow your unconscious mind to let the words flow freely.......

TIP: To maximise the value of the process, simply move through the questions quickly without giving too much thought to your answers. We prefer to get your answers from your unconscious, rather than receiving consciously contrived answers.

QUESTIONNAIRE – Creating a Life Beyond Limts starts here...

First Name (*)
Please enter your first name
Surname (*)
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Street Address (*)
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Suburb
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State/Province (*)
Please select your State/Province
Country
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Daytime Phone
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Email Address (*)
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Mobile Phone
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Birth Date
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Star Sign
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Occupation
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Referred by
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1. How many years/months have you smoked?
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2. What obstacles have I allowed to stop me from quitting for good?
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3. What am I tolerating right now? (in other words, how is smoking negatively impacting my life right now?)
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4. What am I passionate about?
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5. What am I NOT passionate about?
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6. What is ONE thing that I could do (that I’m not doing now) that if I did on a regular basis would make a tremendous, positive difference in my life?
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7. On reflection, is there anything I would have done differently, in the last 5 years?
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8. How many cigarettes am I smoking on average each week? If you are smoking cigars or an illegal drugs, please state these in confidence.
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9. How much is smoking costing me each year? Be as honest as possible.
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10. Physical Costs? What physical costs are you currently paying? E.g. Shortness of breath, tiredness, cough, poor circulation, stroke, cancer, heart condition, etc....
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11. List the most important people in my life and their relationship with you?
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12. What would my friends say about me as a person?
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13. What would my relatives or parents say about me as a person?
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14. What is missing in my life right now?
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15. There are many concepts of a spiritual life and of course just as many religions. Please tick or if receiving a digital file, check the box that best describes what deity represents spirituality to me. (This will help your coach to respect your faith).










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16. Who has a vested interest in me quitting cigarettes for good?
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17. If I had to move to an deserted island to spend the rest of my days there, and could take only 5 things with me, what 5 things would I choose? (Place them in preferential order and list them as individual items, not collections - You cannot take your entire library – instead choose just one book or one CD).
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18. If you just won Million - what (one to five) things would you purchase?
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19. While this might sound like an odd question; What is the benefit to you should you continue smoking?
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20. In our coaching relationship, is there anything I need to know about you to help our communication? How would you like me to communicate to you? E.g.; Do you like direct communication i.e. “the bottom line”, or a more subtle approach?
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21. Is there anything I need to know about your physical or mental health?
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22. What would be a specific measurement of the success of your Quit Smoking Session?
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23. On a scale of 1 to 10 (10 being total commitment) – what is my commitment to getting what I want from my coaching?
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24. Picturing myself as a 100-year-old person looking back at my life. What would I like to have achieved so that I would consider my life to have been fulfilled with no regrets?
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25. Answer this question within 15 seconds, without editing your thoughts. If you secretly knew, why you were here on Earth or what is your purpose, summarise it in one sentence.
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26. Choose Your Coaching Session Package.
Regular packages:

MPORTANT: This provides only an indication of your commitment
and will be determined at the end of your first coaching session.


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Submit Your Questionnaire
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