Smoke-free Homes Promise form Please enable JavaScript in your browser to complete this form.1. How many children/young people live at your address or stay overnight on a regular basis?UnbornAged 0-5 years6-11 years12-17 yearsNone2. How many people who smoke live at your address?3. How many people who live at your address have recently stopped smoking?(Quit smoking in the last two months)4. Now that you have had the chance to look at this leaflet, is there a promise that you would like to take?BronzeSilverGoldDiamondNoneIf you have chosen 'none' why would this be the case?5. Before hearing about this project where did smoking occur in your home?EverywhereIn most roomsIn 1 or 2 roomsOnly at the front/back doorNowhere6. Before hearing about this project did you or anyone smoke in your car?YesNoWe don't have a car7. Where did you find out about this challenge?Pregnancy ScanningStop Smoking MidwifeHospitalFire and Rescue ServiceCommunity PharmacyPlaygroup/NurseryStop Smoking AdviserPrimary SchoolSecondary SchoolMidwifeHealth VisitorPractice Nurse/DoctorSocial WorkSpecial EventOtherIf you found out about the challenge via a 'special event' or 'other', please specify:8. Would you like us to send you a free Smoke-Free Homes Guide?YesNoNo, I've already been given one9. Would you like a Stop Smoking Adviser to contact you?YesNoNo, I already have one10. Would you like the Fire & Rescue Service to contact you to see if you require a free home fire safety visit?YesNoNo, I've already had oneBy ticking ‘Yes’ you are agreeing to us passing on your details to the Fire & Rescue Service.Name *FirstLastAddressPostcode *Telephone NumberNHS Highland has a policy not to pass on your details to anyone else. We may contact you in the future for evaluation purposes to find out how useful this project has been. I consent to NHS Highland contacting me for this purpose. *YesNoGDPR Agreement *I consent to having this website store my submitted information so they can respond to my inquiry.Submit