Enroll

Complete this brief Enroll Now form.

This is a secure and HIPAA compliant website.


What is your preferred language?

* *

What is your gender?

* *

Please enter your first name.

* *

Please enter your last name.

* *

What is your preferred phone number?

* *

Please enter your zip code.

* *

Please tell us when you were born.

* *

Please enter your email address.

* *

In which program would you like to participate?

* *

What tobacco product(s) are you currently using?

* *

Cigarettes

* *

Do you smoke cigarettes every day or some days?

* *

How many cigarettes do you smoke per day on the days that you smoke?

* *

How soon after you wake, do you smoke your first cigarette?

* *

SLT, chew tobacco, snuff, or dip

* *

Do you use chewing tobacco, snuff or dip every day or some days?

* *

How many pouches or tins do you use per week, on the weeks that you use tobacco?

* *

How soon after you wake, do you first use spit tobacco, snuff or chew?

* *

Cigars, cigarillos, or small cigars

* *

Do you smoke cigars every day or some days?

* *

How many cigars, cigarillos or little cigars do you smoke per week on the weeks that you smoke?

* *

How soon after you wake, do you first smoke a cigar, cigarillo, or little cigar?

* *

Pipe with tobacco

* *

Do you smoke a pipe with tobacco every day or some days?

* *

How many pipes do you smoke per week, on the weeks that you smoke?

* *

How soon after you wake, do you first smoke a pipe?

* *

Have you used an e-cigarette or other electronic “vaping” product in the past 30 days?

* *

How many days did you use an e-cigarette or electronic “vaping” product in the last 30 days?

* *

People use e-cigarette/e-vaping products for a variety of reasons, are you currently using e-cigarettes/e-vaping products to quit smoking?

* *

Do you intend to completely quit using e-cigarettes/e-vaping products within the next 30 days?

* *

How long have you been using tobacco products?

* *

Have you used any quit smoking medications with a previous quit attempt?

* *

If ‘other’, what did you use?

* *

How many times have you tried to quit not including this time?

* *

In your most recent quit attempt did you use any of the following methods to quit?

* *

Do you agree to be contacted after this program to ask about our services?

* *

Which of these groups would you say best describes you?

* *

White

* *

Black or African American

* *

Asian

* *

Native Hawaiian or Pacific Islander

* *

American Indian or Alaska Native

* *

Hispanic or Latino/Latina

* *

Do you consider yourself to be gay, lesbian, bisexual, and/or transgender?

* *

Bisexual

* *

Gay or lesbian

* *

Queer

* *

Transgender or gender variant and assigned male at birth

* *

Transgender or gender variant and assigned female at birth

* *

What is the highest level of education you have completed?

* *

What is your marital status?

* *

Do you have any mental health conditions, such as anxiety disorder, depression disorder, bipolar disorder, alcohol/drug abuse, or schizophrenia?

* *

Anxiety Disorder

* *

Depression

* *

Bipolar Disorder

* *

Schizophrenia and Schizoaffective Disorders

* *

Attention-Deficit/Hyperactivity Disorder (ADHD)

* *

Posttraumatic Stress Disorder (PTSD)

* *

Other

* *

Do you currently have a substance abuse condition?

* *

Marijuana

* *

Alcohol

* *

Other drugs

* *

What treatments are you currently using to help with your mental health condition? Check all that apply.

* *

Medication

* *

Counseling

* *

None

* *

During the past two weeks, have you experienced any emotional challenges such as excessive stress, feeling depressed or anxious?

* *

During the past two weeks, have you experienced any emotional challenges that have interfered with your work, family life, or social activities?

* *

Do you believe that these mental health conditions or emotional challenges will interfere with your ability to quit?

* *

Please select a username, which will be used to log into the website.

* *