LGL region smoking cessation referral form

Do you know someone who wants to quit smoking/vaping? This online submission form was developed to help guide you through the 3 A’s of brief tobacco/vaping interventions. It should only take you 3 to 5 minutes to complete and make a referral (if appropriate). After your referral is received, a quit coach will reach out, usually within 2 business days.

If you have any questions about our Smoking Cessation Referral Form, please email quit@southeastph.ca.

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* Referral source

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* Which community partner referred you to this service?

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* Do you need guidance in starting a conversation about tobacco/nicotine use?

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* What is your name?

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* Which city/town do you live in?

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* Please provide a phone number or email address where we can reach you

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* Would you like to receive an email with information about the STOP program and a link for self-enrollment?

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* Please provide an email address for STOP program enrollment.

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* Do you have a partner who is interested in cessation support?

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* What is your partner's name?

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* Which city/town does your partner live in?

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* Please provide a phone number or email address where we can reach your partner

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* Staff name

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* Best way to follow up with staff if needed?

Collection of personal health information:
Personal health information collected on this form (e.g., tobacco and vaping product use and frequency) is kept confidential and used to monitor local data, plan and provide local programs and services, case management, program administration, and program evaluation. You may withdraw your consent to provide additional health information at any time. Any questions about the collection and use of this information or for more information about our privacy practices, contact our Privacy Officer, at privacy.officer@southeastph.ca or call 1-800-660-5853.  Please see our Privacy Statement for more information.

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* Do you consent to the above collection of personal health information as well as being contacted by Southeast Public Health for follow up?

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