Make a referral to the Smoke Free Homes Service (12 to 17 years)

Please complete this form to self refer or refer a young person aged 12 to 17 years to the Smoke Free Homes service.

Why do we ask for personal details?

For young people aged 13 and over, support can usually be provided confidentially. For young people aged 12, a parent or guardian will need to be involved. We will always explain confidentiality and information sharing clearly when we make contact.

Information will only be shared where necessary to keep someone safe or where we have a legal duty to do so.

Referral form tips

Please skip the referred by a school or hospital sections if you are referring yourself.

Young person's details

Note: Questions marked by * are mandatory

*This is a mandatory field. What is the referral type?

Check this box if you are aged 12-17 and referring yourself to the service
Check this box if you are school staff (and referring the young person with consent)

*This is a mandatory field. Full name

Preferred name

*This is a mandatory field. Date of birth

What pronouns do you use?

They/Them
She/Her
He/Him
Other

If you answered other pronouns, please include them here

*This is a mandatory field. Home address

*This is a mandatory field. Contact telephone number

Email address (if available)

*This is a mandatory field. Preferred method of contact

Phone
Text
Email

*This is a mandatory field. Do you consent to receiving text message appointment reminders?

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Make a referral to the Smoke Free Homes Service (12 to 17 years)

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Make a referral to the Smoke Free Homes Service (12 to 17 years)

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