Therapist Aid Cessation Log Form
Track your progress and experiences as you work towards cessation. Use this log to record urges, triggers, coping strategies, and outcomes to support your journey.
Full Name
*
First Name
Last Name
Date and Time of Entry
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Behavior or Habit Addressed (e.g., smoking, alcohol, etc.)
*
Did you experience an urge or craving since your last entry?
*
Yes
No
If yes, please rate the intensity of your urge/craving.
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
What was the main trigger for your urge/craving?
Stress
Social Situation
Boredom
Negative Emotion
Environmental Cue
Other
What coping strategy did you use?
Deep Breathing
Exercise/Physical Activity
Contacted Support Person
Distraction (e.g., hobby, reading)
Mindfulness/Meditation
Other
Outcome of this episode
*
Resisted the urge (no lapse)
Lapsed (engaged in the behavior)
How did you feel after this episode?
Proud
Disappointed
Neutral
Motivated
Frustrated
Other
Reflections or notes (optional)
Would you like to share this log entry with your therapist?
*
Yes, share with my therapist
No, keep private
Submit Log Entry
Should be Empty: