Referral form | Shropshire Council

Shropshire Healthy Lives Stop Smoking Service can help you, whether you’ve tried to quit before, you’ve been thinking about quitting for a while or you’re only just considering stopping smoking.The service offers free, confidential support from a specialist stop smoking advisor to help you stop smoking. It supports tobacco smokers aged 12 years+ living or working in the Shropshire Council area or registered with a Shropshire GP, who would like to help to quit smoking.

The current arrangements enable our advisors to offer 12 weeks of behavioural support, including four weeks’ funded supply of licensed NRT treatment following NRT assessment. NRT includes nicotine patches and oral products. Currently, prescription-only medications, eg Varenicline, Bupropion (Zyban) and Cytisine fall outside the scope of the service offer.

For more information or to book a direct appointment take a look at our stop smoking page.

For our privacy notice go to our privacy pages.

Consent

Is this referral for yourself?

Yes

No - I am a carer/family member referring with consent of the person who requires support

No - I am part of a referring organisation making this referral on behalf of someone else

Your details (as the person referring)

Referrer's organisation name and job title

Referrer's full name

Referrer's email address

Referrer's contact number

Details of the person being referred

Full name

Email address

Best contact number

Full address

GP practice

Any additional supporting information (smoking info/access info/known risks/best time to contact)