2. Date
   Date
4. Name*
5. Title
7. Organization*
9. Address*
11. City*
12. State*
13. Zip
15. Counties Served*
17. Days
18. Hours
20. Business Phone*
21. Fax
23. Email*
24. Website
26. Tobacco Cessation Program Name
    (if applicable; e.g. Freedom From Smoking)
30. Description of Services
32. How frequently do you offer tobacco cessation services?

    Check all that apply.

    1. Weekly
    2. Regularly Scheduled: Cessation services are provided on a regularly scheduled basis, e.g. every Thursday night.
    3. Whenever: Whenever a group can be formed.
    4. On Demand
    5. Other
34. If other, please specify:
36. Which of the following services does you agency/organization offer?

    Check all that apply.

    1. Individual Face-to-Face Counseling
    2. Group Counseling
    3. We Initiate Telephone Calls for Client Counseling
    4. We Respond to Telephone Calls for Client Counseling
    5. Self-Help Materials
    6. Acupuncture
    7. Hypnosis
    8. Other
38. If other, please specify:
40. In what language(s) are cessation services provided?

    Check all that apply.

    1. English
    2. Spanish
    3. Other
42. If other, please specify:
44. Which of the following self-help materials does you agency/organization offer?

    Check all that apply.

    1. Brochures
    2. Books
    3. Audiotapes and/or Videotapes
    4. Internet Materials
    5. Other
46. If other, please specify:
50. Delivery of Products and Services
52. When are services provided?

    Check all that apply.

    1. Mornings
    2. Afternoons
    3. Evenings
    4. Weekends
54. How do people register for your cessation services?

    Check all that apply.

    1. By Phone
    2. In Person
    3. By Mail
    4. By Referral From Insurance Provider
    5. By Email
    6. Other
56. If other, please specify:
58. For each client, what is the average duration of an entire program?
60. Number of Sessions
    Record duration in numbers of sessions per period of time, e.g., 1 session per week for 6 weeks.
62. Number of Weeks
64. Other, Please Specify
66. What age groups do your services target?

    Check all that apply.

    1. Younger Than 18 Years Old
    2. 18-24 Years Old
    3. 25-34 Years Old
    4. 35-65 Years Old
    5. 65 and Older
68. Do you charge a fee for your cessation program?

    1. Yes
    2. No
70. How much do you charge for cessation services? Total cost:
72. Do you offer a sliding scale?

    1. Yes
    2. No
74. Would you like your services listed in a Jefferson County Cessation Resource List?

    1. Yes
76. Would you like this information forwarded to the Washington State Tobacco Quitline to be offered to callers from Jefferson County?

    1. Yes
78. Thank you for your help in creating a safer and healthier Jefferson County.
Leave This Blank:


80. 1. Receive an email copy of this form.
81. Email address

    This field is not part of the form submission.

82. Submit

* indicates a required field