Share a Nicotine Cessation Service with Washington Breathes

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Please use this form to make us aware of a nicotine cessation service that is not yet listed on our Cessation/Quitting Support Services webpage. Please fill out as much information as possible by responding to the questions below.

We will review all submissions before adding them to our website. We ask for your contact information in case we have questions.

Note: You do not need to sign in to a Google account to complete this form. Please ignore any prompts to do so.

Name of the Nicotine Cessation Service *

Description of the nicotine cessation service, including a link or contact information. *

What is the format of the nicotine cessation service? (check all that apply)

Online

Phone App

Telephone

In-person

Other:

Where is this nicotine cessation service or resource available? (please check all that apply)

Nationwide

Washington State

Regional Level

Local Level

Please describe where the service or resource is available.

Is this cessation service available to anyone wanting to stop using nicotine? Or is it restricted or designed for a specific group?

Other Comments or Information To Share? *

Please provide your contact information so that we can contact you with any questions.

Your First Name *

Your Last Name *

Your Pronouns

Your Email *

Your Organization or Affiliation
*

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