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

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

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

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, if you have physical accessibility needs, or you need an interpreter or easy-read communications.

Is there any disability?
Do you require an interpreter?
Required