Stop Smoking Service Referral Form

The Stop Smoking Service provides individualised support to give you the best chance of quitting and staying smokefree. 

Read more about the Stop Smoking Service and the options available to you.

To be contacted about the Stop Smoking service, please complete the online form below. Alternatively, you can phone: 0800 NO SMOKE (0800 667 665) or email: [email protected].

Fields marked with an asterisk (*) must be completed before the form can be submitted.

Note: Your information is safe with us. The personal information you give to us via an online form is not stored on our website, or accessible from this site. See our Privacy Disclaimer for more information.