What habit do you want to quit?
Smoking Overeating Nail Biting Procrastination Other
How long have you had this habit?
Less than 1 year 1-3 years 3-5 years Over 5 years
Have you tried quitting before?
Yes, many times Yes, a few times No, never
What’s your preferred session type?
In-person Online Either
When do you want to start sessions?
Immediately Within a month Within six months Undecided
All set, how can we reach you?
Name
Email
Phone
(Details here)
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