Get the free QuitLine Referral Form - University of Illinois Springfield

The Illinois Tobacco Quit line is a FREE resource for tobacco users who want to quit for good. Our registered nurses, respiratory therapists, and certified tobacco treatment counselors are on call

How to fill out quitline referral form

How to fill out quitline referral form

1. To fill out the quitline referral form, follow these steps:
2. Obtain a copy of the quitline referral form.
3. Read the instructions on the form carefully.
4. Fill in your personal information such as name, address, and contact details.
5. Answer the questions regarding your smoking habits and addiction.
6. Provide any relevant medical history or current medications you are taking.
7. If necessary, indicate whether you have any preferences or special instructions for the quitline counselor.
8. Double-check all the information you have entered to ensure accuracy.
9. Sign and date the form at the designated space.
10. Submit the completed form to the designated recipient or organization as instructed.
11. Keep a photocopy of the form for your records if needed.

Who needs quitline referral form?

1. Anyone who is looking for support and assistance to quit smoking may need a quitline referral form.
2. This form is typically required by organizations or healthcare providers that can provide resources and counseling to help individuals quit smoking.
3. It is also beneficial for individuals who want to access additional services or medications that are available through quitline programs.
4. Whether you are trying to quit smoking for the first time or have previously attempted quitting, a quitline referral form can be a useful tool to seek professional help and guidance.

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What is quitline referral form?

The quitline referral form is a document used to refer individuals who wish to quit smoking or tobacco use to professional smoking cessation services, such as a quitline.

Who is required to file quitline referral form?

Healthcare providers, counselors, or organizations that assist individuals in quitting tobacco are typically required to file a quitline referral form on behalf of their clients or patients.

How to fill out quitline referral form?

To fill out the quitline referral form, provide the necessary information about the individual seeking help, such as their name, contact information, smoking history, and other relevant details as specified on the form.

What is the purpose of quitline referral form?

The purpose of the quitline referral form is to facilitate access to tobacco cessation resources and support, ensuring that individuals receive the help they need to quit smoking.

What information must be reported on quitline referral form?

The quitline referral form typically requires information such as the individual's name, contact details, date of birth, smoking history, and any relevant health conditions.