ITQL - REFERRAL AGENCY PORTAL

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REFERRAL AGENCY PORTAL
1-866-QUIT-YES

1-866-784-8937

Tobacco Treatment Enrollment Form

PARTICIPANT INFORMATION

First Name

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Last Name

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Mailing address

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City

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State

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Zip Code

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Email address

This field is required in correct email format.

Phone Number

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Alternate Phone

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Date of birth

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Gender

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Race/Ethnicity

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Language

English

Spanish

Other (specify)

May we leave a message?

Yes

No

Pregnant

Yes

No

Medicaid Participant

Yes

No

When should we call?

7am-10am

10am-1pm

1pm-4pm

4pm-7pm

7pm-9pm

Anytime

This field is required.

CLIENT CONSENT

I authorize this agency to release the information on this referral form to the Illinois Tobacco Quitline (ITQL) for purposes of my participation in the tobacco cessation program. I also authorize the ITQL and its representatives to contact me at the phone number(s) and/or email listed above. I give the ITQL permission to discuss my use of service.

Please check the box to provide your consent.

AGENCY STAFF: Please select the method in which participant consent was obtained

Obtained in person

Obtained on phone

REFERRING AGENCY INFORMATION

Agency Name

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Contact Name

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Contact Number

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Agency Contact Email

This field is required in correct email format.

Today's Date

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