Response Details

Just to confirm, your last name is n, e, v, e, s ; one word. Is that correct?

What's your date of birth?

What's your phone number?

What's your email address? This will become your login.

Just to confirm, your email address is v, i, n, i, at, u, s, t, w, o, dot, c, o, m. Is that correct?

What's your address?

Please tell me about your current health insurance. I'll read a list of options, and you can tell me which one describes your situation. a. Uninsured; b. Both Medicaid and Medicare (Dual Covered); c. Medicaid; d. Medicare; e. Military Insurance (TRICARE); f. Prefer not to say; g. Private/Commercial/Employer-Based; h. Other (a health plan that is not Medicaid or Medicare); i. I don't know.

To help you become tobacco-free, we can connect you with a live coach by phone, text, or chat. You can also choose our online program if you prefer using our digital tools. Which option sounds better for you — phone or online?

To help us better support you, how would you describe your current pregnancy or postpartum status, including any plans you might have to become pregnant?

Are you Hispanic or Latino?

How would you describe your race?

Do you have any of the following behavioral health conditions? I'll read a list and please tell me which ones apply to you. a. Anxiety; b. Attention Deficit Hyperactivity Disorder; c. Bipolar disorder; d. Depression; e. PTSD or recent trauma; f. Schizophrenia; g. Regular use of Cannabis; h. Regular drinking more than 5 alcoholic drinks in a day; i. Other drug abuse or Substance Use Disorder; j. None of these; k. I don't know; l. Prefer not to say.

Would you like to share your personal feedback on the program to help provide a better experience to members like you?

How would you describe where you are in your quit journey right now — have you already quit, do you feel ready to quit, or do you want to quit but aren't quite ready yet?

Setting a Quit Date will give you time to prepare and a better chance of quitting. If you don't have a Quit Date, we recommend setting one two weeks from today. When would you like to set your quit date for? You can always change this later.

Working with a coach is the best way to stay on track with quitting, and it's totally private and confidential. When can a coach call you during the week? - would you prefer mornings, afternoons or evenings?

When would you like a coach to call on the weekend? - would you prefer mornings, afternoons or evenings?

Would you like to receive emails about personalized feedback, program information and progress updates? If yes, your consent to receive these emails is not a condition of participating in Quit Services. Even if you do not opt in, you will still receive transactional communications such as personalized session reminders by joining the program. Please note: These emails may include your personal health information and may be tailored to your personal experience in Quit Services. Email is not a fully secure method of communication and carries some risk of being read by a third party. You may opt out of your consent to receiving emails by changing your email preferences. a. Yes; b. No.

Would you like to enroll in text messaging to receive program tips and reminders? a. Yes; b. No.

Would you like to enroll in Quit Buddy to receive automated tips and messages from an AI chatbot Coach? a. Yes; b. No.