Quitline Referral

Acknowledgement *: I acknowledge that the client/patient named has been provided with information about the Quitline and has provided verbal informed consent to their information being sent to the NSW Quitline.

Surname *:

Given Names *:

Postcode *:

Gender Identity:

Female
Male
Non-binary
Prefer to self-describe mandatory

Preferred phone number *:

Preferred date of first call:

Preferred day/s to call:

Weekdays

Mon
Tue
Wed
Thu
Fri

Preferred time/s to call:

8am to 12pm
12pm to 4pm
4pm to 7pm

Weekends

Sat

Preferred time/s to call:

9am to 12pm
12pm to 4pm

Is it OK to leave a message?

Yes
No

Interpreter required? Yes

If yes, specify language:

Is the client/patient of Aboriginal or Torres Strait Islander origin?

Yes
No
Not stated/unknown

Client requests an Aboriginal counsellor?

Yes
No

Relevant health conditions: (To be filled by health professionals only with patient consent)

Diabetes
Heart Disease
Respiratory Disease
Asthma
Depression
Anxiety
Pregnancy
Breastfeeding
Cancer

Other, please specify: