This service is to support people who would like to quit or reduce their tobacco usage.

You can refer yourself or by any healthcare professional (including GPs) for the Specialist Smoke free service for pregnancy and people with mental health. 

Section 1: Referral source

Which service referred you to us? Required

Please only complete referrers information if you are a healthcare practitioner making a referral on behalf of someone else.

If you are referring yourself, please skip this part and move to Section 2 (Patient details)

Referrer information

Section 2: Patient details

Please complete the mandatory fields marked with an * to ensure we can process your referral.

Date of birth Required
Address Required
Are you currently smoking? Required
Are you currently pregnant? Required
Do you have a mental health condition? Required
Are you experiencing any mental health symptoms? (For example, stress, anxiety, or low mood?) Required

Section 3: Accessibility and communications needs

Please tell us if you have any accessibility or communication needs so that we can ensure you have a positive experience accessing the service. For example, please let us know if you have any physical accessibility needs, need an interpreter or easy-read communications, or if you need assistance in arranging appointments.

Do you have a disability?
Do you need additional communication support, such as braille, large print or easy-read formats?
Do you require an interpreter?