QuitPath Intake Assessment

The QuitPath program is designed to help those who want to quit smoking. Information gathered in this survey may be shared with researchers to unsure the quality of programs offered in the Yukon are meeting the needs of Yukoners. Your personal contact information is kept confidential and is required for participation in the QuitPath program; all other questions are optional.

Question Title

* Date:

	Month	Day	Year
Today's date	Today's date Month menu	Today's date Day menu	Today's date Year menu

Question Title

* Personal information:

Full name:

Question Title

* Contact information:

City/Community:

Postal code:

E mail address:

Primary day phone#:

Alternative phone #:

Thank you for giving us your contact information. A Quitpath coach will be in touch with you shortly so that we may assist you on the road to living smoke-free again.