Referral form

If you would like to access stop smoking support, please complete the form below and we will contact you.

Please note that we can only take referrals from residents of Stockton-on-Tees Borough Council.

If you are a resident from the Hartlepool Borough Council area, please see Hartlepool Now for your local service.

I understand that by completing this form I give permission to the NHS Stop Smoking Service to store my information in order to contact me to offer me support to become a non smoker*
- I agree
First name*
Last name*
Date of birth*
What is your sex?*
Contact number*
Address*
Postcode*
Can we leave you a voicemail?*
Preferred contact time*
- 9am - 12midday
- 12 - 2pm
- 2pm - 4pm
- No preference
*Please note that every effort will be made to contact you at your preferred time but that there may be occasions when this is not possible. Thank you.
Can we send you a text message?*
Can we write to you if we are unable to contact you by telephone?*
Healthcare professionals
Name Role Organisation Special instruction/s

If you are a health professional completing this referral please leave your details here
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Name	Role	Organisation	Special instruction/s