MetroHealth Online Freedom from Smoking® Program

Any information given on this form is voluntary and will remain confidential. It will help us to determine your individual  needs to quit so that the correct treatment is available for you. Please ask the program leader if you have any questions about this form at 216-778-3031 or email

** Participants will not be admitted after the second session
Are you a MetroHealth patient? *
Which of these describes your ethnic group? *
What is your gender identity? *