Quitline Referral Form

Using a service like Quitline can greatly increase a person’s chance of successfully quitting smoking.

Quitline is a confidential, non-judgmental telephone-based support and information service. Our counsellors encourage and support people at all stages of their smoking journey; from the thinking stage to being ready to quit, right through to assisting those who have already quit or relapsed.

Our friendly team of qualified counsellors use an evidence-based approach and are trained in all areas of smoking cessation. The service is free.

To refer a patient or client to Quitline, simply complete the Referral Form below or download the Quitline Referral Form. Download

For further information email admin@quittas.org.au or phone (03) 6169 1943.

Quitline Referral

Referring organisation
Name of organisation referring*
Name of person referring*
Phone*
Fax
Email*
Client Details
Name*
Preferred phone number*
Notes
(eg: ATSI status, health concerns, pregnancy, etc)
Consent*
I have acknowledged the privacy policy.
Privacy is important to us and we treat your information with respect, integrity and honesty in keeping with our core values and as governed by the Privacy Act. Personal information is only collected as necessary for agreed Quit programs or activities. Please visit our Privacy Statement. If you have any queries please don’t hesitate to contact us on 03 6169 1943 or by email admin@quittas.org.au
The above question is for testing whether you are a human visitor and to prevent automated spam submissions.
The above question is for testing whether you are a human visitor and to prevent automated spam submissions.

Using a service like Quitline can greatly increase a person’s chance of successfully quitting smoking.

Quitline Referral

Referring organisation

Client Details

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