Arkansas Be Well Baby Self Referral Form

Arkansas Be Well Baby Self Referral Form
You're in the right place.

Be Well Baby offers free, confidential support to help you quit smoking or vaping during pregnancy. You’ll get nonjudgmental coaching, proven tools to keep you motivated, and encouragement every step of the way. Plus, earn hundreds in gift cards for baby essentials —just for staying on track.

What you can expect:
- One-on-one support
- Coaching without judgment
- A healthier start for you and your baby
- Rewards to celebrate your progress
Fill out the form below to take the first step.

You’ve got this—and we’ve got you.
Program Eligibility
Are you pregnant and 36 weeks gestation or less?*
Are you currently using tobacco/vaped nicotine/any form of nicotine, quit since becoming pregnant, or quit within 3 months of becoming pregnant?*
You indicated that you currently use or have previously used tobacco/nicotine but are not pregnant. Because of this, you are not eligible to enroll in the Be Well Baby Program. We encourage you to visit Be Well Arkansas for additional support and resources.
Based on the information provided, you are not eligible to enroll in the Be Well Baby Program. If you have further questions, please Contact Us.
How did you hear about us?*
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Estimated Due Date*

MonthDayYear
Date
State*
Zip Code*
Today

MonthDayYear
Date
Age
Agency ID*
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Arkansas Be Well Baby Self Referral Form

Program Eligibility

Personal Information