Phone Coaching

First Name*

Middle Name

Last Name*

Preferred Name

Date of Birth*

Address*

City*

State*

Zip Code*

Phone*

Alternative Phone

Legal Sex

Ethnicity

Race

Preferred Language

Have you used the program before?

What are the best times for the Maine QuitLink to call?:
MorningAfternoonNo Preference

Is it ok to leave a message at this number?:
YesNo

* Required Fields

Tell Us A Little About You

How did your hear about our program?

Are you active service or a veteran from any branch of the US Military, including the National Guard or Reserves?

What is the highest level of education you have completed?

What terms best describe your sexual identity?

If you are female and age 50 or younger: Are you currently pregnant, planning a pregnancy in the next few months, or postpartum within 12 months?

Have you been diagnosed with any of the following chronic conditions?
(Check all that apply)AsthmaCancerChronic Bronchitis (COPD or CLRD)Coronary Artery Disease (CAD)Heart Failure (CHF)StrokePre-Diabetes/DiabetesNoneI Don’t KnowPrefer Not To Say

Do you have any known behavioral health conditions such as anxiety, depression, bipolar disorder, schizophrenia, substance use disorder, ADHD, or PTSD?

If yes, based on your answer do you think it will be more difficult for you to quit?

What is your health plan or health insurance? This service, including medication support, is free regardless of this answer. We are asking to better understand the reach of our program

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Tell Us About Your Tobacco Use

What tobacco and nicotine products have you used in the past 30 days (Check all that apply)?
CigarettesSpit or Smokeless TobaccoCigars/CigarillosPipeE-CigarettesOther Vaping ProductsNone

Cigarettes

Do you smoke menthols?

Do you currently smoke cigarettes every day, some days, or not at all?

How many cigarettes do you smoke per day on the days that you smoke?

Cigars/Cigarillos

Do you currently smoke cigars every day, some days, or not at all?

How many cigars do you smoke per day on the days that you smoke?

Smokeless Tobacco

Do you currently use chewing tobacco, snuff, or dip every day, some days, or not at all?

How many tins per week do you use?

Vapes

Do you currently vape every day, some days, or not at all?

How soon after you wake up do you first use tobacco or e-cigarettes?

Are you ready to start your quit journey in the next 30 days?
YesNoI Don't Know

Are you interested in getting free Nicotine Replacement Therapy (nicotine patches, nicotine gum, or nicotine lozenges) from the Maine QuitLink?
YesNoI Don't Know

Is it ok to contact you in the future to assess whether you are satisfied with the service
YesNo