Description
“I’m fine all day. It’s three in the morning that gets me.” By the next session they can’t tell you what the thought was — only that they lost to it.
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. Every page was built for the hour a client wakes and reaches for tobacco, by a nurse with twenty-five years in pulmonary care who is also a certified quit coach.
Why the 3 AM hour, and not willpower
Most quit plans are written for daytime. The hour that ends them is 3 AM, when a client cannot read a chapter and cannot think their way out. What works then is one page, prepared in advance, that gives the hour something to do.
Waking in the first weeks is common and it is not a sign the quit is failing. Nicotine is a stimulant and the body takes time to settle without it. Page 1 says so, in language a client can take in at three in the morning.
What you get
Four pages — US Letter and A4 both included — 97 fillable fields.
Plus the license page, in both sizes.
1 — The Midnight Mind-Calmer
The client marks the hour they woke, reads a short calm explanation of why nicotine withdrawal wakes people, writes down the promise the craving is making, and decides the next ten minutes.
2 — The 3 AM Nervous System Reset
Four steps for the middle of the night, in the dark, without waking anyone: a temperature check, a slow-exhale breathing anchor, a body scan and the 20-minute rule. Urge rated before and after.
3 — The Insomnia Overthinking Ledger
A full-page brain dump beside a three-step thought check: the thought, what the client has actually seen happen, and the answer they choose for tonight.
4 — The 14-Night Smoke-Free Sleep Log
Fourteen nights on one sheet: date, wake time, urge from 1 to 5, which reset helped, smoke-free yes or no.
How it sits in a session
Page 1 carries the withdrawal explanation in plain language, including a line on nicotine replacement and quit medication that directs the client back to you rather than to a change made alone.
Page 2 is a down-regulation sequence with a pre and post urge rating, so the client brings you a number rather than an impression.
Page 3 is a cognitive behavioral thought record, laid out for someone completing it alone, at night, without you in the room. The middle step asks for the client’s own observed evidence rather than a reframe you supply.
Page 4 gives you fourteen nights of data on one sheet. That is the page to open at the next appointment.
Nothing on these pages asks for a diagnosis, 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 — which is the point, because this is a page needed at 3 AM, not at a printer.
- Or print it for the drawer beside the bed.
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.