Enroll

Complete this brief Enroll Now form.

This is a secure and HIPAA compliant website.

What is your preferred language?

Please tell us how we can best assist you.*



Please enter your first name.*

Please enter your last name.*


Please enter your phone number:

Home:

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Work:

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Please enter your street address:

Address:

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City:

State:

What is your zip code?*

County:

Do you spend at least 50 percent of your time in North Dakota?*

Please enter your email address*
(If you do not have email, or wish to not provide an email address, please call 1-800-QUIT-NOW)

Please tell us when you were born.*

(MM/DD/YYYY)
 

What is your gender?*

Please tell us how you found NDQuits.*
















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

Cigarettes *


Chewing tobacco, snuff or dip *


Cigars, cigarillos, or little cigars *


Pipes *


eCigarettes *


Other tobacco products *


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?*









We’d like to ask you some additional questions about yourself. We are collecting this information to ensure we are reaching all populations. Please remember that your answers are completely confidential.

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






Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, government plans such as Medicare, Medicaid or Indian Health Services? *

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







Are you Hispanic or Latino/Latina?*


Do you consider yourself to be gay, lesbian, bisexual, and/or transgender? *

What is your marital status?*




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?
 

Please tell us which program you are interested in.*
If you select Online program only, you will not receive calls from a Quit Coach

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.

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.

*Indicates required information