Skip links and keyboard navigation

Refer a client to Quitline

Quitline is a free confidential support service for people who want to quit smoking.

Clients should consent to receiving a call from Quitline prior to this form being completed.

To refer a client to Quitline, complete the online referral below.

Or, you can download and print the Quitline referral form (PDF 269 kB)

Privacy notice

Personal information, including sensitive information, collected by the Department of Health is handled in accordance with the Information Privacy Act 2009. The purpose of this form is so that patients may be referred to the Quitline service for information, advice and assistance. All personal information will be securely stored and only accessible by authorised officers of the department. Demographical information, such as gender, age group, suburb and cultural background may be used for our statistics, but will not include any identifiable information. Personal information will not be disclosed to third parties without consent, unless required or authorised by law. For further information, including an individual's right to access their own personal information, please see our website.

Required fields are marked with an asterisk (*).

Client details
Gender *
Is the client of Aboriginal or Torres Strait Islander origin? *
(This information will help us to facilitate tailored support for the client, such as linking the person with an Aboriginal and/or Torres Strait Islander counsellor and program where appropriate)
Would they prefer to speak to an Aboriginal and/or Torres Strait Islander counsellor?
Date of birth *
(DD/MM/YYYY)
Call details
Preferred phone number *
Include area code 07 for all landline numbers
Can Quitline leave a message?
Health issues
Condition
Optional questions
Client would prefer a...
Does the client require the National Relay Service?
Is a translator needed?
Referrer's details
Complete this section if referring from a Queensland Health Facility


Health practitioner declaration

I have given the patient a verbal explanation of the Quitline service and informed them that their personal information will be provided to the Department of Health, including their health information, for the purpose of referring them to the Quitline service.

I have also informed the patient that the Department of Health will contact them direct in relation to their referral and seek consent regarding participation in Quitline and any disclosure of their personal information to third parties.

I have provided the patient with a copy of the Quitline brochure which provides further information on how their personal information will be handled by the Department of Health and how they can seek access to their personal information.



Last updated: 22 May 2018