Complete this brief Enroll Now form.

What is your preferred language?

What is your gender?*

What is your zip code?*

Please enter your first name.*

Please enter your last name.*

Please enter your phone number.*


Please enter your email address.*

Please tell us when you were born.*


Please tell us how we can best assist you.*

Please tell us how you found NDQuits.*

Please tell us where you are at in the quit process.

What types of tobacco have you used in the past 30 days?*

After you participate in this program, someone may contact you by email or phone to ask you a few questions about our services. We use this information to improve our program. Your participation in the evaluation is voluntary.

On a scale of 1 to 10, with 1 being not at all confident and 10 being highly confident, how confident are you that you can quit using tobacco?*

Several communities have been targeted by the tobacco industry or have higher smoking rates. We have some specific materials for people in these communities. So we'd like to ask you some demographic questions. Please remember that your answers are completely confidential.

What is the highest level of education that you have completed? *

Are you Hispanic or Latino/Latina?*

Which of these groups would you say best describes you?*

What is your marital status?*

Do you consider yourself to be: *

Would you say that in general your health is excellent, very good, good, fair, or poor? *

Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? *

Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? *

NDQuits offers a free text messaging program to supplement your coaching calls. Through this program, you will receive motivational messages, appointment reminders, and other messages while enrolled in the coaching program. Standard text messaging rates will apply. Are you interested in signing up for the text messaging program? *

Please tell us which program you are interested in.*

Please select a username, which will be used to log into the website. *
Note: username must be at least 6 characters. You can use letters and numbers. The first character must be a letter.

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