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.

This following part of this section only needs to be completed if a healthcare practitioner is making a referral on behalf of someone. If you are referring yourself, please use the self-referral form.

Referrer information

Required
Required

Section 1: Patient Details

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

Date of birth Required
Required
Address Required
Are you currently smoking? Required
Are you currently pregnant? Required
Is there any disability?

Section 2: Accessibility and Communication 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, if you have physical accessibility needs, or you need an interpreter or easy-read communications.

Do you require an interpreter?

Section 3: How Did You Hear About Us?

How did you hear about us? Required
Required