Ready to Quit

Ready to Quit Form

Please fill out this form to receive a call from a Quit Coach at the Maine Tobacco Helpline, and to have self-help materials mailed to you.

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