NTMI Participant Registration Details

Staff to transfer hard copy data to this form

* 1. Course ID number:

* 2. Have you been hospitalised due to your mental illness within the past 12 months?

* 3. Course location:

* 4. Participant ID # (initials, course number, birth year. ie DG179)

* 5. date Of Birth:

DOB

* 6. Gender

* 9. Participation goals. Would you like to:

* 10. Have you ever tried to quit before?

* 11. What is the longest you have gone without smoking?

* 12. What are your main reasons for wanting to quit/cut back?

* 13. Have you been to any other tobacco related support groups previously? Was it a NTMI group?

* 14. Are you currently participating/involved with any other mental health organisation(s) or support groups? if so which ones?

* 15. Permission to send to Dr or Support worker

* 17. Do you live with other smokers

* 20. Do you have any of the following health problems?

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