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Self-referral form - part 1

I am currently smoking tobacco; cigarettes, etc.

I am prepared to stop smoking completely.

I will keep appointments with my stop smoking adviser.

I will observe the advice given to me by the stop smoking adviser.

I will attend a clinic in person, in order to have my carbon monoxide levels monitored (blow into a CO-monitor)

I am committed to make all efforts that I reasonably can to ensure my quit attempt is successful.

I am confident that this is the right time to stop smoking and that I can make this a priority for me (in other words, there are no other things going on in my life right now that would make it too hard for me to give up smoking).

I understand that if I do not keep appointments the service may discharge me.