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2. Thank you for expressing interest in quitting nicotine. We offer group classes and one-one counseling in person or online.

4. Let us know which of our nicotine cessation services you are interested in:

   1. One-on-one counseling for yourself
   2. One-on-one counseling for your child
   3. Quitting nicotine before, during, or after pregnancy
   4. Managing nicotine withdrawal
   5. Preventing nicotine (vaping, smoking) use by my teenager
   6. Group classes online
   7. Group classes in person
   8. Other
6. If you checked other, please tell us more.
8. Contact Information
10. Name
11. Email Address
13. Address
15. City
16. State
17. Zip Code
19. Phone Number
21. How did you hear about us?

    1. Flyer at work
    2. Social media post
    3. Health Department homepage
    4. Email
    5. Word of mouth
    6. Presentation
    7. Resource fair
    8. Other
23. If you checked other, please let us know how you heard about our services.
25. Do you need interpreter services?

    1. Yes
    2. No
27. Do you need an assistive listening device?

    1. Yes
    2. No
29. Questions?

    Use this space to ask us any question you may have about the classes. We will answer them in our reply to you. 

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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

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