Smoke-Free Virginia: Cessation Programs To Help You Stop Smoking or Using Tobacco

Smoking cessation resources to guide you on your way to a healthier lifestyle.

If your organization provides any kind of smoking cessation resource to community members and you would like to apply to have it included in the Resource Directory of the Smoke-Free Virginia website, please print out, complete, and mail or fax this form to: Janis Dauer, Program Manager, Alliance for the Prevention and Treatment of Nicotine Addiction, 3557 Chesapeake Blvd #1, Norfolk, VA 23513, phone (757) 858-9934, fax (757) 858-8464.

Organization: _____________________________________________________________________________________

Program or Department: ____________________________________________________________________________

Contact Person's Name: ____________________________________________________________________________

Telephone: ______________________________________       TTY: ________________________________________

Quitlines/Helplines: additional toll-free #: ______________________________________________________________

Program Email: ________________________________   Website: http:// _____________________________________

Program Address: _________________________________________________________________________________

City: _________________________________________________  State: ______  Zip code: ______________________
                  (required)

__ Yes  __No  Is this a statewide program?
__ Yes  __ No  Is this program site wheelchair accessible?
__ Yes  __ No  Is this program site accessible by public transportation?
__ Yes  __ No  Is childcare available on site?

Brief description of the program: (check all that apply)

__ Face-to-face counseling
__ Group counseling
__ Telephone counseling (Quitline or Helpline)
__ Inpatient services