Social Service Providers

Quit Referral Form

As a social service provider, you are a trusted resource for your clients who are asking about tobacco use. You can increase their odds of successfully quitting by providing brief intervention and connecting clients to evidence-based tobacco treatment, like the Maine Tobacco HelpLine.

Please complete this form to connect your client to the Maine Tobacco HelpLine. They will receive a call from a Quit Coach with more information and have the opportunity to enroll in the free HelpLine counseling program.

This request is for:

MyselfSomeone Else


Please make sure you have the permission of the individual whose information is being submitted as the HelpLine does need to speak with that individual directly.

Please specify:

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Recommended for quick response

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What are the best times for the Maine Tobacco Helpline to call?

8am - 11am11am - 2pm2pm - 5pmAfter 5pm

Is it ok to leave a message at this number?

YesNo