Quit Coaching Order Form

3. Enrollment Materials

Space Cell	10	25	50
Trying to reach you postcard	Trying to reach you postcard: 10	Trying to reach you postcard: 25	Trying to reach you postcard: 50
Baseline Survey	Baseline Survey: 10	Baseline Survey: 25	Baseline Survey: 50

4. Required Forms

Space Cell	10	25	50
Check-In Survey	Check-In Survey: 10	Check-In Survey: 25	Check-In Survey: 50
Home Visit Survey Packet	Home Visit Survey Packet: 10	Home Visit Survey Packet: 25	Home Visit Survey Packet: 50
Combined Counseling Guide + Visit Summary Packet	Combined Counseling Guide + Visit Summary Packet: 10	Combined Counseling Guide + Visit Summary Packet: 25	Combined Counseling Guide + Visit Summary Packet: 50
CO FAQ	CO FAQ: 10	CO FAQ: 25	CO FAQ: 50

5. Tobacco Handouts and Counseling Tools

Space Cell	10	25	50
Action Plan	Action Plan: 10	Action Plan: 25	Action Plan: 50
Nicotine Dependence	Nicotine Dependence: 10	Nicotine Dependence: 25	Nicotine Dependence: 50
Understanding Triggers	Understanding Triggers: 10	Understanding Triggers: 25	Understanding Triggers: 50
Managing Cravings	Managing Cravings: 10	Managing Cravings: 25	Managing Cravings: 50
Slip vs Relapse	Slip vs Relapse: 10	Slip vs Relapse: 25	Slip vs Relapse: 50
Staying Quit	Staying Quit: 10	Staying Quit: 25	Staying Quit: 50
Protecting Kids from Tobacco Smoke	Protecting Kids from Tobacco Smoke: 10	Protecting Kids from Tobacco Smoke: 25	Protecting Kids from Tobacco Smoke: 50
Social Support	Social Support: 10	Social Support: 25	Social Support: 50
Stress and Smoking	Stress and Smoking: 10	Stress and Smoking: 25	Stress and Smoking: 50
Breastfeeding and Smoking	Breastfeeding and Smoking: 10	Breastfeeding and Smoking: 25	Breastfeeding and Smoking: 50
Mental Health & Quitting	Mental Health & Quitting: 10	Mental Health & Quitting: 25	Mental Health & Quitting: 50
Quit Smoking Meds	Quit Smoking Meds: 10	Quit Smoking Meds: 25	Quit Smoking Meds: 50
Congratulations (You Quit/You Cut Down)	Congratulations (You Quit/You Cut Down): 10	Congratulations (You Quit/You Cut Down): 25	Congratulations (You Quit/You Cut Down): 50
Certificate of Completion	Certificate of Completion: 10	Certificate of Completion: 25	Certificate of Completion: 50
E-Cigarettes	E-Cigarettes: 10	E-Cigarettes: 25	E-Cigarettes: 50
Weight Management & Smoking	Weight Management & Smoking: 10	Weight Management & Smoking: 25	Weight Management & Smoking: 50
Risks - Baby	Risks - Baby: 10	Risks - Baby: 25	Risks - Baby: 50
Risks - Mom	Risks - Mom: 10	Risks - Mom: 25	Risks - Mom: 50
Craving Journal	Craving Journal: 10	Craving Journal: 25	Craving Journal: 50
Refer a Friend (Business Cards)	Refer a Friend (Business Cards): 10	Refer a Friend (Business Cards): 25	Refer a Friend (Business Cards): 50
Enter another option	Other: 10	Other: 25	Other: 50
Enter another option	Other: 10	Other: 25	Other: 50

6. Substance Use Handouts

Space Cell	10	25	50
Cannabis - general info	Cannabis - general info: 10	Cannabis - general info: 25	Cannabis - general info: 50
Cannabis - pregnancy & breastfeeding	Cannabis - pregnancy & breastfeeding: 10	Cannabis - pregnancy & breastfeeding: 25	Cannabis - pregnancy & breastfeeding: 50
Cannabis - caregiving	Cannabis - caregiving: 10	Cannabis - caregiving: 25	Cannabis - caregiving: 50
Stimulants - what to know/types	Stimulants - what to know/types: 10	Stimulants - what to know/types: 25	Stimulants - what to know/types: 50
Stimulants - pregnancy & breastfeeding	Stimulants - pregnancy & breastfeeding: 10	Stimulants - pregnancy & breastfeeding: 25	Stimulants - pregnancy & breastfeeding: 50
Stimulants - caregiving	Stimulants - caregiving: 10	Stimulants - caregiving: 25	Stimulants - caregiving: 50
Opioids - what to know/types	Opioids - what to know/types: 10	Opioids - what to know/types: 25	Opioids - what to know/types: 50
Opioids - pregnancy & breastfeeding	Opioids - pregnancy & breastfeeding: 10	Opioids - pregnancy & breastfeeding: 25	Opioids - pregnancy & breastfeeding: 50
Opioids - caregiving	Opioids - caregiving: 10	Opioids - caregiving: 25	Opioids - caregiving: 50
Alcohol - general info	Alcohol - general info: 10	Alcohol - general info: 25	Alcohol - general info: 50
Alcohol - pregnancy & breastfeeding	Alcohol - pregnancy & breastfeeding: 10	Alcohol - pregnancy & breastfeeding: 25	Alcohol - pregnancy & breastfeeding: 50
Alcohol - caregiving	Alcohol - caregiving: 10	Alcohol - caregiving: 25	Alcohol - caregiving: 50
Tobacco - general info	Tobacco - general info: 10	Tobacco - general info: 25	Tobacco - general info: 50
Tobacco - pregnancy & breastfeeding	Tobacco - pregnancy & breastfeeding: 10	Tobacco - pregnancy & breastfeeding: 25	Tobacco - pregnancy & breastfeeding: 50
Tobacco - caregiving	Tobacco - caregiving: 10	Tobacco - caregiving: 25	Tobacco - caregiving: 50
Prescription depressants (sedatives)	Prescription depressants (sedatives): 10	Prescription depressants (sedatives): 25	Prescription depressants (sedatives): 50
Ketamine	Ketamine: 10	Ketamine: 25	Ketamine: 50
Hallucinogens	Hallucinogens: 10	Hallucinogens: 25	Hallucinogens: 50
Inhalants	Inhalants: 10	Inhalants: 25	Inhalants: 50
Prescription Drug Misuse	Prescription Drug Misuse: 10	Prescription Drug Misuse: 25	Prescription Drug Misuse: 50
Overdose Prevention	Overdose Prevention: 10	Overdose Prevention: 25	Overdose Prevention: 50
Enter another option	Other: 10	Other: 25	Other: 50
Enter another option	Other: 10	Other: 25	Other: 50

8. Well Badger Materials

Space Cell	10	25	50
WB Rack Card - English	WB Rack Card - English: 10	WB Rack Card - English: 25	WB Rack Card - English: 50
WB Rack Card - Spanish	WB Rack Card - Spanish: 10	WB Rack Card - Spanish: 25	WB Rack Card - Spanish: 50
COVID-19 Help Postcard (English one side, Spanish other)	COVID-19 Help Postcard (English one side, Spanish other): 10	COVID-19 Help Postcard (English one side, Spanish other): 25	COVID-19 Help Postcard (English one side, Spanish other): 50

9. Supplemental Forms & Materials

Space Cell	10	25	50
FB Referral Form	FB Referral Form: 10	FB Referral Form: 25	FB Referral Form: 50
Quit Line Cards	Quit Line Cards: 10	Quit Line Cards: 25	Quit Line Cards: 50
Fax to Quit Form	Fax to Quit Form: 10	Fax to Quit Form: 25	Fax to Quit Form: 50
Release of HC Information Form	Release of HC Information Form: 10	Release of HC Information Form: 25	Release of HC Information Form: 50