Devon Stop Smoking Service Referral Form

Healthy Lifestyle support is for:

Myself

Someone else

Your details:

Referrer's details:

First name(s)

Your name

Last name

Referral Category

Date of birth

Referral Subcategory

Referral Source

Preferred language

Referral Source

Mobile number

Your job title

Email address

Your email address

Postcode

Your telephone number

Client's details:

Consent

Client's first name(s)

I consent to the release of relevant personal information about myself to the Stop for Life Devon service. I understand this information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controller is my referrer.

I understand that I have (i) the right to change my mind about being referred to the service and to withdraw consent and (ii) right of access to my information.

Client's Last name

Please tick this box if you consent to this service

Sex assigned at birth

Please note that we aim to contact you within two full working days of receiving your information

Gender

Ethnicity

Date of birth

Preferred language

Contact number

Mobile number

Postal address

Email address

Postcode

In order to ensure we can offer the client the appropriate level of service, it is important we have the following information. If you don't feel it appropriate to ask, we will seek this information on our initial call with the client.

Please tick the box if any of these apply:

Diagnosed mental health conditions

living with a long-term medical condition

Routine and manual worker

learning disability

Pregnant smokers and others living in the household (e.g., partners, parents)

misuse substances

Children and young people under 18

Unemployed people

children in care and care leavers/care experienced

refugees and asylum seekers

experiencing homelessness

living in social housing

in contact with the criminal justice system

ethnically diverse people

LGBTQ+

GRT communities (Gypsy, Roma and Traveller)

Clients who have already been supported by level 2 intermediate advisors (in primary care or pharmacy) and have had 2 unsuccessful quit attempts should be offered a referral to specialist stop smoking advisors within the Devon Stop Smoking Service.

Client consent

Please advise the person you are referring:

I consent to being referred to Stop for Life Devon. The nature and purpose of which has been explained by my referrer.

The referral process requires their personal data to be processed to allow the Stop for Life Devon service to contact them.

Please ask them if they consent to the above. Confirm by ticking this box

If the client declines to give consent, please advise: Unfortunately I cannot refer you to the service. You can contact the service direct on stopforlife.devon@nhs.net