Tobacco Treatment Program Application

Tobacco Treatment Policies & Guidelines

Eligibility Criteria

Use tobacco products.
Live in our four-county service area.(Benton, Madison, Carroll and Washington).
Or if you are cancer patient receiving treatment in our four-county service area.
Or you are a spouse/caregiver to a patient receiving cancer treatments.

Program Details

Hope Cancer Resources provides free tobacco treatment counseling over the phone or in person.

Treatment Program Policy

Weekly communication is required from the participant and will be assessed on an individual basis.
After 2 unsuccessful attempts of outreach, the Tobacco Treatment Specialist will mail a follow up letter to be sent to the address on file and no further attempts will be made.
Nicotine Replacement Therapies (NRT) such as patches, gum or lozenges can be provided as part of the tobacco treatment plan but are not required. Typically NRT will be provided on a weekly basis via mail.
Hope Cancer Resources can provide payment assistance of prescription treatment medication ie. Chantix/Varenicline or Wellbutrin/Bupropion when the participant has exhausted over-the-counter NRT options and/or the individual’s Physician recommends it for treatment. A prescription can only be picked up at Highlands Oncology Pharmacy unless otherwise worked out with Tobacco Treatment Specialist.
Hope Cancer Resources provides services to anyone in our service area with a qualifying cancer diagnosis. Services available to patients are approved or denied on a case-by-case basis. Hope Cancer Resources reserves the right to refuse services at our discretion on factors including but not limited to availability of resources, patient conduct, and responsible engagement of services.

Please allow up to 10 business days for tobacco treatment requests.

The mission of Hope Cancer Resources is to provide compassionate, professional cancer support and education in the Northwest Arkansas region today and tomorrow.

Our Tobacco treatment Program is supported by the Hope Cancer Resources Foundation.

Name*

First NameLast Name

Preferred Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number

Please enter a valid phone number.

Cell Phone Number

Please enter a valid phone number.

Sex assigned at birth*

Social Security Number

Are you over 18?*

Date of Birth*

Date

Ethnicity*

Are you pregnant or breast feeding?*

Have you ever been diagnosed with cancer? *

Are you currently receiving cancer treatment?

Please select all that apply

Please select all types of tobacco that you are currently using.*

How much product do you use per day?

By cigarette/cigar/vape per day or can/pouch per day.

On a scale of 1 – 10, how important is it to you that you quit using tobacco?*

On a scale of 1-10, how confident are you that you can quit using tobacco?*

On a scale of 1 -10 how ready do you feel to quit using tobacco?*

Do you have a quit by date?

Date

Tobacco Treatment Program Application

Tobacco History

Information Release or Alternate Contact