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

If you have been referred by a healthcare professional (including GPs) or if you would like to refer yourself, please complete the form below.

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.

Required
Required
Date of birth Required
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?
Required