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Smoking Cessation
Are you filling this form for yourself
- Select -
Yes
No (see below)
form-filler Information
Name person completing the form for someone else
Organisation Name completing the form for someone else
HertsHelp
Community Navigator (HCNS)
NHS Acute
Foodbank
Good Neighbour Scheme
Harpenden Cares
Parish/Town Council
District Council
County Council
CVS/Volunteer Centre
Phone number completing the form for someone else
Email address completing the form for someone else
Client Details
First Name
Last Name
Birth Date
Street Address
City
Postal Code
Phone Number
Email
Health Information
Have you got a long term conditions
Yes
No
Have you got a mental health condition?
Yes
No
Have you made 2 or more previous quit attempts?
Yes
No
Are you awaiting surgery?
Yes
No
Have you a disability?
Yes
No
Are you currently using nicotine products or vaping?
Yes
No
Are you being discharged from hospital?
Yes
No
Discharge Date
Have you had a baby in the last 12 months?
Yes
No
Baby's Date of Birth
Are you pregnant?
Yes
No
Are you the partner of a pregnant person?
Yes
No
Details of any conditions or disabilities
Consent
By ticking this box, I give my consent for Communities 1st to share my personal information with the National Health Service (NHS) and other relevant parties for the purpose of facilitating my participation in the smoking cessation service and any associated services that may be identified as beneficial during my journey. I understand this information will be used to provide comprehensive support and resources tailored to my specific needs in smoking cessation and related health matters.
I give consent
By ticking this box, I confirm that as the referring organisation, we have obtained explicit consent from the individual being referred to Communities 1st for the smoking cessation service. I verify that the individual has been fully informed about, and has agreed to, the sharing of their personal information with Communities 1st and, as necessary, with the National Health Service (NHS) and other associated services, for the purpose of facilitating their participation in the smoking cessation program and any related services.
I have obtained consent
