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shl@nf.lung.ca
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register - online group program
Register – Online Quit-Smoking Group Program
Name
*
Email
*
Phone Number
*
Postal Code
Which of the following best describes you?
Please select
I currently smoke
I used to smoke but I have since quit and am now smoke free.
When did you quit?
Date Format: MM slash DD slash YYYY
How did you hear about the NL Smokers' Helpline website?
Please select
On the tobacco package health warnings
Link from other website
Facebook
From a healthcare provider
From family/friends
From a Helpline counsellor
Pamphlet
Radio
Television
Newspaper
At my workplace
At my school
At a community organization
Don't Know
Do you remember which website?
Do you remember which station?
Do you remember which channel?
Gender
male
female
Year of birth (YYYY)
Do you currently smoke cigarettes:
Daily
Occasionally (if less than 7 days per week or less than 1 cigarette per day)
Not at all
How many cigarettes do you smoke per day on the days that you smoke?
How soon after you wake up do you smoke your first cigarette?
Within 5 minutes
6-30 minutes
31-60 minutes
More than 60 minutes
I don't smoke
How ready do you feel to quit?
Planning to quit in the next 30 days
Planning to quit in the next 6 months
Not planning to quit in the next 6 months
Once registered, you will receive an email with everything you need to know to join the online group. In the meantime, if you would like additional support, the Helpline will text you once per day (weekdays, 5 texts per week) with tips and information to help you move forward with quitting.
Would you like to receive daily text messages from the Helpline?
Yes
No thanks
Please let us know if there is a different phone number that we should use for texts. If so, enter it below.
One of the key services of the Helpline is over-the-phone support where you can discuss strategies and your quit plan with one of our ‘quit coaches’. You’re going to get LOTS of help through the online group program, however if you would like extra one-on-one support over-the-phone then we will call you.
Would you like to receive a follow-up phone to discuss the Smokers' Helpline services and to discuss your personal plan to quit or reduce your smoking?
Yes
No thanks
Please let us know if you prefer that we call at a specific time of day. For ex., let us know if it is best for us to call in the Morning, Afternoon or Evening.
When we try calling, is it okay for us to leave a message if we reach a voice mail or if someone else answers the phone?
Yes
No
During the past 12 months, how many times did you stop smoking/using tobacco for at least 24 hours because you were trying to quit?
Please select
Once
Twice
Three times or more
Not applicable
To ensure we are providing the best service to our clients, an independent evaluation of our service is conducted on an ongoing basis. If you are willing to participate in this evaluation, a surveyor from Health Canada may contact you in 7 months. Your name and email and additional information you provided using this service will be used for evaluation purposes only; your name and email will be destroyed after you participate in the evaluation.
Would you like to take part in the evaluation?
Yes
No thanks
Captcha
Name
This field is for validation purposes and should be left unchanged.
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1-800-363-5864
shl@nf.lung.ca
15 Pippy Place, St. John's, NL
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