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Quitline Referral
Quitline Referral
All fields mark with
*
are compulsory. fields marked with
*
are conditionally compulsory.
Client Details:
*
Title:
Mr
Mrs
Ms
*
Name:
*
Address:
*
Postal Code:
Contact Phone Number (please provide the best phone number for contact at the time of the requested call)
*
Home:
*
Work:
*
Mobile:
*
Date of Birth:
(dd/mm/yyyy)
Aboriginal or Torres Strait Islander origin?
Yes
No
Interpreter?
Yes
No
If yes, language:
Time for first call (allow up to 30 minutes):
Day:
Monday
Tuseday
Wedneday
Thursday
Friday
Saturday
*
Date:
(dd/mm/yyyy)
*
Best Time to Call:
8:30am-1pm Mon to Fri
1pm-5pm Mon to Fri
5pm-8pm Mon to Fri
2pm-5pm Sat
In compliance with the 2001 Privacy Bill, Quit SA is required to ask the following questions:
Can Quitline send reports to your referring health care provider informing of your quitting progress?
Yes
No
May our evaluation unit ring you for quality control purposes?
Yes
No
Referring professional details:
*
Name:
Organisation:
*
Profession:
GP
Nurse/Midwife
Mental Health Worker
Aboriginal Health Service Worker
Drug & Alcohol worker
Community Services Worker
Dentist
Pharmacist
Other
*
Organisational Setting:
General Practice
Health Care Service
Pharmacy
ATSI Worker
Hospital
Dental Practice
Other
Address:
Postal Code:
*
Contact Phone:
*
Email:
*
Type of referral:
Youth (15-29 years)
Disadvantaged (health care card holder)
Pregnancy
Pregnancy-partner/family
Culturally & Linguistically Diverse (CALD)
General/Other
For any questions, please phone the Quitline on 8291 4282.
