Be Smoke Free Manchester

If you are making this referral on behalf of someone else, please ensure they have consented to receive support to stop their tobacco use.

When you go through the form, don't use your normal 'Back' button to return to an earlier question.
Use the 'Previous' button at the bottom of the page you are on.
Questions marked * can't be left blank.

You have about 20 minutes to fill in this form.