Description
“I can’t do this while there’s still someone smoking in the house.” The client isn’t asking for more willpower. They’re asking what to do about a person they live with.
For clinicians, coaches and quit advisors
Plenty of worksheets let you print and use them with clients. This one does too. Here is what it adds.
- You may give a client their own blank copy to keep, by email or through a secure patient portal.
- You may use it in groups you run yourself.
- You may print without limit, for as long as you practice.
- And a written license page comes as a separate sheet in the download, so your practice has something to file.
One practitioner. Not transferable to a colleague, and not for resale.
Written for smoking cessation
Not adapted from general therapy material. The boundary requests, the rehearsed answers and the one conversation do not exist on a general relationship sheet, because they are built around a household where one person is quitting and the other is not — by a nurse with twenty-five years in pulmonary care who is also a certified quit coach.
Why the household, and not willpower
Every other page you hand a client assumes they decide what happens next. Clear the house. Plan the mornings. Choose the response.
Not this one. This client did all of that, and then someone they love lit one in the kitchen.
It is worth knowing what that actually looks like, because clients rarely say it out loud. They get through the morning and they are proud of the morning. Then the back door opens and closes, and thirty seconds later the smell comes in on someone’s clothes, and the whole body knows exactly what it wants. They say nothing, because it is that person’s house too.
They start listening for the door.
Underneath it sits the part that is harder to admit: they are doing the difficult thing and the other person is not. Some evenings that comes out as resentment, and then guilt about the resentment. Some evenings it is a small voice saying this is unfair — and unfair is one short step from why bother.
That is the week three collapse, and it is not a willpower problem.
What you get
Four pages — US Letter and A4 both included — 148 fillable fields.
Plus the license page, in both sizes.
1 — Setting the Boundary Plan
Three specific requests, each with a line for what the client does if the answer is no. An envy and resentment reframe. A thirty-day log, one house per day, for proving to themselves that the choice was theirs.
2 — When It Happens Right Now
The ten-minute move, in order: leave the room, give the hands something, say the sentence already chosen, come back. Rehearsed answers to the three things smokers actually say, with room for the ones only this client hears. A four-week check-in.
3 — What I Tell Myself About Them
A cognitive behavioral thought record aimed at the belief about the other person. Not what the client fears about them — what they have watched them do. Urge rated before, the chosen answer rated after.
4 — The Conversation, Once
When to ask, the three things to ask for, what they are explicitly not asking for, how to end it if it turns, and a line to fill in the same evening.
How it sits in a session
Page 1 is the opening exercise. The three requests are deliberately about the house rather than about the person, which is what makes them answerable.
Page 2 is what the client takes home for the moment itself. The rehearsed answers are decided while calm, so nothing has to be found in the moment.
Page 3 is where this client is usually stuck. “He is doing it on purpose.” “She does not want me to stop.” The middle step asks for their own observed evidence rather than a reframe you supply.
Page 4 is the one that changes the household. A request made weekly stops being a request and becomes a complaint, and that is what wears the relationship down alongside the quit. This page is for asking once, properly, and then letting the answer stand.
Nothing on these pages asks the client to speak for the other person, and nothing is scored.
Three ways to use it
- Hand a client one page, or all four.
- They type straight into it on a phone or tablet.
- Or print it — the thirty-day log was made to be colored in by hand.
Two sizes, both fillable
US Letter, 8.5 x 11 in — United States and Canada
A4, 210 x 297 mm — the standard size everywhere else
Both are in the download at no extra cost, and both work the same way: type on screen, or print. The fields do not show on paper.
Before you start
Open the file in Adobe Acrobat Reader — it’s free, on iPhone, Android, Mac and Windows. A browser preview will show the pages, but it won’t reliably keep what a client types.
Keep the blank original blank. Save filled copies under a new name.
The practice license
One practitioner, unlimited clients, worldwide. Print for your own clients, use one-to-one and in groups you run yourself, send a blank copy to an individual client, and keep a filled copy in a client file where your recordkeeping rules require it. Not for resale, and not transferable to a colleague — each practitioner needs their own. The full terms come as a separate page in the download.
Personalized license copy, on request
The license page carries the name of this set and has fields for your name, your practice, and the date of purchase, so you can complete it yourself and keep it with your records. If you would rather have those details typeset into the page instead of typed into a form field, write to hello@cessationworksheets.com after your purchase and I will send one back. No charge — it is part of the license.
How buying works
Checkout runs through Gumroad, a payment platform used by independent creators worldwide. You pay on their secure checkout page, and your card details never reach me.
The price shown here is $7.99 before tax. VAT or sales tax is added at checkout, based on where you live, so the total can differ from country to country. You see the full amount before you pay.
Charges are processed in US dollars. Outside the United States, your bank converts the amount and may add a small fee of its own.
Straight after payment you get a download link on screen and by email, with both files — A4 and US Letter — and a receipt.
Who wrote this
I am a pulmonary nurse, trained in asthma and COPD. I work in a respiratory outpatient clinic, where I see people with asthma and COPD and run the smoking cessation consultations. I am listed in KABIZ, the Dutch quality register for healthcare professionals, which means I work to the national care standard for tobacco and nicotine dependence.
Evidence-informed and developed with reference to current tobacco-dependence and smoking-cessation guidelines, using CBT-informed behavioral tools to support structured cessation conversations.
Every page is built on national standards for tobacco dependence and on published evidence, and checked against the guidance in each. See the seven guidelines.
No lectures. No scare tactics.
Instant digital download. Nothing is shipped. No refunds once the download has been opened. If the file does not work as described, write to me and I will sort it out.
Support tool only — not medical advice, and not a substitute for the clinical judgment of the practitioner using it.