Need help or advice?

Vibe referral form for young people

Welcome to Vibe

We offer confidential support to help young people with stopping smoking, vaping or both.

If your school is not part of Vibe, you can still get support from your school public health nurse drop-in or text Chat Health on 07507 330025 for vaping support. You can also visit Live Life Better Derbyshire for stopping smoking support.

If you are a young person, you can refer yourself to Vibe by completing the form below.

About you

Name (first and last name) Required

Date of birth (dd/mm/yyy) Required

School Required

Year group Required

Support wanted

What support would you like? Required

Consent and contact

Do you agree to Vibe contacting you? You will be contacted within 2 working days; our number may show as unknown/private. Required

Preferred method of contact (select all that apply) Required

Text

Phone call

Mobile number

Email address

When is the best time to contact you? (Select all that apply) Required

Before school

Lunch time

After school

Other (please tell us time of day)

If you selected 'other' please tell us what time would be best to contact you

Any other information

Please tell us anything about yourself that might help us support you

Confidentiality

We only share information if we are worried that you or someone else is at risk of harm. Please tick to tell us you understand this. Required

I agree to the privacy policy

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