Community Organizations

The Quitline is a free service offering telephone coaching, online help, text messaging and quit medications. As part of a conversation about quitting tobacco, you can offer to make a referral to connect your client to additional support. If your client agrees to the referral you can use the form below. After you send the send referral form, the Quitline will reach out to your client to offer tobacco cessation services.

*= Required

Referred Individual

First name

Last Name

DOB

Primary phone type

Primary Phone

Extension

Secondary phone type

Secondary Phone

Extension

Address

Address 2

City

State

Zip Code

Preferred language

The individual has consented to receiving text messages with motivational messages tailored to them and other program events, such as appointment reminders, and quit anniversaries.

Yes

Standard message and data rates may apply. The individual may opt-out at any time.

Is it ok to leave a voicemail?

Yes

Is the individual hearing impaired?

Yes

If yes, please specify:

Referring Organization

Contact First Name

Contact Last Name

Organization name

Organization Address

Organization address 2

Organization city

Organization state

Organization zip code

Organization Phone Number

Authorization

As a Not Covered Entity, personal health information will not be shared back for the individual being referred.

By submitting this form, I verify that the individual being referred has consented to participate in the tobacco cessation program.

Thank You

Thank you for the referral.
The Quitline will call your patient within 24 hours.