If you would like a free assessment to check whether we can help you quit smoking in 60 minutes, please complete the following assessment form.

Note: 100% SECURE. Your details are retained with complete confidentiality.

First Name
Last Name
Contact Number
Why do you think you haven't been able to quit up until now?
What are your reasons for why you want to quit smoking?
Are you quitting for yourself or because somebody else wants you to?
Please note any concerns you have about quitting smoking and any questions or concerns you may have about the Quit Smoking in 60 Minutes system. Write NONE if you have no concerns.
What are the best times for us to contact you?
How did you hear about us?
If you were referred to us by someone, please enter their name below so that we could thank them