Looking to quit smoking? Our Sunderland Health coaches can help you. 

Referrals criteria

• You must be registered with a GP Practice in Sunderland
• Anyone aged 14 years and above.  You must commit to a 12-week programme.
• Prenatal and postnatal women. You must commit to a 16-week programme.

If you would like support, please fill out the referral form below – (please choose Smoking Cessation for Reason for Referral from the drop-down list)

Making a Referral

*Please note all fields are required

Who is making this referral?

Patient

Professional

Link Worker

Self Referral

Full Name

As shown on medical record

Would prefer to be known by / What name do you prefer to be called?  Optional

Date of Birth

Day

Month

Year

Are you registered with a GP in Sunderland?

Yes

No

To use this service you need to be registered with a GP. Click here to find a GP Practice in your area.

Are you homeless?

Yes

No

Address

Street Address Address Line 2 City Postcode

Name of GP registered

Please select..Not registered with a GPAshburn Medical CentreBridgeview Medical GroupCastletown Medical CentreChester Road SurgeryConcord Medical GroupDeerness Park Medical GroupDr Gellia and BalaramanForge Medical PracticeFulwell Medical CentreGalleries Medical PracticeGrangewood SurgeryHappy House SurgeryHerrington Medical GroupHetton Group PracticeHoughton Medical GroupHylton Medical GroupI J HealthcareKepier Medical GroupMillfield Medical GroupMonument Surgeries (Barmston and Galleries)New City Medical PracticeNew Silksworth Medical GroupNew Washington Medical GroupPallion Family PracticePark Lane PracticeRedhouse Medical CentreRickleton SurgeryRiverview SurgerySouth Hylton Medical GroupSouthlands Medical GroupSpringwell Medical GroupSt Bede's Medical CentreThe Broadway Medical GroupThe Stephenson Medical Practice (Dr Stephenson and Partners)Village SurgeryVillette SurgeryWearside Medical PracticeWestbourne Medical Group

Patient Contact number

Email  Optional

Reason for Referral

Please Select..Adult Social Care/ Occupational TherapyCancerCarerDomestic ViolenceEmployment SupportFinancial AdviceFrequent GP AttenderFuel SupportHousingLong Term Condition ManagementMenopauseMental Health IssuesPhysical InactivitySmoking CessationSocial IsolationSubstance MisuseWeight Management

Where did you hear about this service?  Optional

Please selectText from PracticeSunderland Health and Wellbeing HubSocial Media e.g. FacebookYour GP Practice WebsiteOther

Additional Information: Please provide extra information regarding the referral

Professional Referral

Do you have the patient's consent to make this referral?

Yes

No

You must have patient consent to proceed

Name of Professional

Service Name

Telephone of Professional

Email of Professional

Any Identifiable Risks ?

Yes

No

Risks

Full Name of Patient

Patient's Date of Birth

Day

Month

Year

Is the Patient Homeless?

Yes

No

Address

Street Address Address Line 2 City Postcode

Name of GP registered

Please select..Not registered with a GPAshburn Medical CentreBridgeview Medical GroupCastletown Medical CentreChester Road SurgeryConcord Medical GroupDeerness Park Medical GroupDr Gellia and BalaramanForge Medical PracticeFulwell Medical CentreGalleries Medical PracticeGrangewood SurgeryHappy House SurgeryHerrington Medical GroupHetton Group PracticeHoughton Medical GroupHylton Medical GroupI J HealthcareKepier Medical GroupMillfield Medical GroupMonument Surgeries (Barmston and Galleries)New City Medical PracticeNew Silksworth Medical GroupNew Washington Medical GroupPallion Family PracticePark Lane PracticeRedhouse Medical CentreRickleton SurgeryRiverview SurgerySouth Hylton Medical GroupSouthlands Medical GroupSpringwell Medical GroupSt Bede's Medical CentreThe Broadway Medical GroupThe Stephenson Medical Practice (Dr Stephenson and Partners)Village SurgeryVillette SurgeryWearside Medical PracticeWestbourne Medical Group

Patient's Contact Number

Patient's Email  Optional

Reason for Referral

Please Select..Adult Social Care/ Occupational TherapyCancerCarerDomestic ViolenceEmployment SupportFinancial AdviceFrequent GP AttenderFuel SupportHousingLong Term Condition ManagementMenopauseMental Health IssuesPhysical InactivitySocial IsolationSubstance MisuseWeight Management

Additional Information: Please provide extra information regarding the referral  Optional

Link worker (Outreach)

Do you have the patient's consent to make this referral?

Yes

No

You must have patient consent to proceed

Name of Link worker

Event / Outreach venue

Full Name of Patient

Patient's Date of Birth

Day

Month

Year

Is the Patient Homeless?

Yes

No

Patient's Address

Street Address Address Line 2 City Postcode

Name of GP registered

Please select..Not registered with a GPAshburn Medical CentreBridgeview Medical GroupCastletown Medical CentreChester Road SurgeryConcord Medical GroupDeerness Park Medical GroupDr Gellia and BalaramanForge Medical PracticeFulwell Medical CentreGalleries Medical PracticeGrangewood SurgeryHappy House SurgeryHerrington Medical GroupHetton Group PracticeHoughton Medical GroupHylton Medical GroupI J HealthcareKepier Medical GroupMillfield Medical GroupMonument Surgeries (Barmston and Galleries)New City Medical PracticeNew Silksworth Medical GroupNew Washington Medical GroupPallion Family PracticePark Lane PracticeRedhouse Medical CentreRickleton SurgeryRiverview SurgerySouth Hylton Medical GroupSouthlands Medical GroupSpringwell Medical GroupSt Bede's Medical CentreThe Broadway Medical GroupThe Stephenson Medical Practice (Dr Stephenson and Partners)Village SurgeryVillette SurgeryWearside Medical PracticeWestbourne Medical Group

Patient's Contact Number

Patient's Email  Optional

Reason for Referral

Please Select..Adult Social Care/ Occupational TherapyCancerCarerDomestic ViolenceEmployment SupportFinancial AdviceFrequent GP AttenderFuel SupportHousingLong Term Condition ManagementMenopauseMental Health IssuesPhysical InactivitySocial IsolationSubstance MisuseWeight Management

Additional Information: Please provide extra information regarding the referral

Phone  Optional

This field is for validation purposes and should be left unchanged.

Benefits of quitting smoking

For more information about quitting smoking please click here