Parent Advisory Cessation Log Form
Please use this form to record and update cessation-related details and follow-up actions. All entries are for advisory tracking only.
Date of update
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent or advisor full name
*
First Name
Last Name
Name of individual supported
*
Cessation topic
*
Please Select
Tobacco
Vaping
Alcohol
Screen time/device use
Other
Current cessation status
*
Active attempt
Maintaining cessation
Relapsed
Planning to start
Actions taken since last update
Provided encouragement
Shared resources
Scheduled a follow-up
Connected with support group
Other
Preferred method of contact for follow-up
Phone call
Text message
Email
In-person meeting
Next follow-up date (if scheduled)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Progress or support satisfaction
1
2
3
4
5
Additional comments or notes
Submit Log Entry
Should be Empty: