Contact information

Please provide your details so that I can send your customized quiz results to the right place.

First Name

Last Name

Email *

Where should I send your customized quiz results?

Phone *

By providing my email and phone number, I agree to be contacted and to receive email and text messages from Clear Path Counseling.

What habit or loop are we targeting?

Habit *

Less than 6 months

6 months to 2 years

2 to 5 years

More than 5 years

We've always had these patterns - they go way back

When the urge hits, what happens FIRST?

(choose one option)

Trigger *

Emotions kick in (stress, anxiety, boredom, loneliness)

A trigger spot hits (time of day, place, people, situations)

My body flips the switch (tight chest, racing heart, numbness)

No clear pattern — it's random

How long has this been running your life?

Quiz Duration Landed *

Under 6 months

6–24 months

2–5 years

5+ years

What's this costing you MOST right now?

(choose one option)

Quiz Cost Landed *

My health or energy

My confidence (tired of the "tomorrow I'll quit" lie)

My relationships or daily mood

My time or wallet

Not sure yet — but I'm done with it

What have you tried so far?

Quiz Attempts Landed *

Pure willpower (white-knuckling)

Talk therapy (insight but no real change)

Med, patches, or substitutes

Apps, books, or programs

Haven't tried much — I'm ready to start

If we found the right fix, when would you start?

Quiz Timeline Landed *

Immediately (this month)

Next 1–2 months

3+ months from now

Just exploring for now

I'm private-pay only (100% confidential). Which best fits your situation?

Quiz Insurance Intent Landed *

Ready to invest in real results

Open, but need process details first

Need insurance-covered options only

Quick safety check:

Quiz Safety Landed *

Active suicidal thoughts or self-harm urges

Psychosis, mania, or recent hospitalization

Immediate crisis or danger

None of the above