Social Service Provider Referrals

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 tobacco or vaping by providing a brief intervention and connecting clients to evidence-based tobacco treatment, like the Maine QuitLink.

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

Additional resources and support is available for providers:

    This request is for:

    MyselfSomeone Else

    Describe Your Role:
    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:

    Name (* Required):

    Address (* Required):

    Town (* Required):

    State (* Required):

    Zip (* Required):

    Email (Recommended):

    Phone (* Required):

    What are the best times for the Maine QuitLink to call?:
    8am - 12pm12pm - 3pm3pm - 6pm6pm - 8pm

    Is it ok to leave a message at this number?:

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