Quitline Referral Form Using a service like Quitline can greatly increase your 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 organisationName of organisation referring*Name of person referring*AddressPhone*Email* Client DetailsGenderMaleFemaleOtherNameMailing addressPreferred phone numberWhat are the patient's health issues relevant to Quitline counsellors?Year of birth*Are you of Aboriginal or Torres Strait Islander origin?*NoYes, AboriginalYes, Torres Strait IslanderYes, Aboriginal and Torres Strait IslanderDo you give consent to send this referral to Quitline and to also contact you to follow up? YesThe above question is for testing whether you are a human visitor and to prevent automated spam submissions.