Make a referral to Stop Smoking Support

Service access criteria

Tick to confirm you have checked the service access criteria "Barking and Dagenham Residents / People that work in Barking and Dagenham / age 12+ /pregnant or living with someone who is pregnant/diagnosed with mental health condition/long term condition , have COPD or living with someone with COPD, waiting for surgery/have a routine or manual occupation/ pregnant or post-natal Havering residents and their partners"

Your Details

Who are you referring?

Don't know / client doesn't have an email address

Additional referral details

For referrals onto a healthy lifestyle programme, I confirm that my patient is clinically stable and compliant with medications and recommend them for support to make a lifestyle change.

Confirmation and consent

Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy
Tick to confirm the service provider can directly contact the client

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