My Commitment to Become a Non-Tobacco User



                The Reasons Why I Use Tobacco:                                                 Why I Want to Stop Using Tobacco:




















                 



                  I will become a non-smoker on
    __________________________________________

date


                                                                                       ________________________________________________________________________

Signed


Print, complete and bring this form with you to our session!

Woods Hypnosis Center

1310 E College Way Ste 110

(360) 333-8577