Smoking Cessation Guidance Form

Please complete this form to give the HERC information regarding you and your smoking habits. Once the form is submitted, a HERC individual will reach out!

Name Name * First Last
Phone Phone * - ### - ### ####
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email *
What is your classification at EIU? *

What is your classification at EIU? Student Faculty Staff Spouse or Significant Other of EIU staff, faculty, or student
How long have you been smoking? *

How long have you been smoking? 6 months or less 7 months to a year 1 - 3 years 4 - 7 years 8 - 10 years More than 10 years I recently quit smoking I have not smoked for more than 1 year
How did you find out about this resource?