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iCanQuit
For health professionals

NSW Quitline referral form

This form is for health professionals who want to refer a client to the NSW Quitline counselling service. If that’s you, please complete the form below. Our team will support your client in their journey to quit smoking or vaping.

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Please ensure all entered information is obtained with consent from the client.

Please see the NSW Quitline privacy statement for more information.

Client details

For example, 08 09 1990
Would they like to speak with an Aboriginal counsellor? *

Client support needs

Current health conditions
Client is seeking support for

Client call preferences

Preferred day(s) for Quitline to call client
Preferred call time (weekdays)
Preferred call time (weekends)
Is an interpreter required?
If the client misses Quitline’s call, do they give permission for the counsellor to leave a voicemail? *
Does the client give permission for us to send SMS reminders before their call? *

Referrer details

Please enter details about the referring health professional (you).

Preferred contact method *

Profession *
Professional setting *
I confirm that the client/patient listed on this form has been informed about the services offered by NSW Quitline and has provided verbal consent for their information to be shared with NSW Quitline. *