Indiana Self Referral Form

Baby & Me Tobacco Free Program Self Referral Form
You're in the right place.

Baby & Me Tobacco Free 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?*
Do you live in Miami or Scott County, Indiana?*
You indicated that you currently use or have previously used tobacco/nicotine but are not pregnant or does not reside in Miami/Scott County. Because of this, you are not eligible to enroll in the Baby & Me – Tobacco Free Program. We encourage you to visit Quit Now Indiana for additional support and resources.
Based on the information provided, you are not eligible to enroll in the Baby & Me Tobacco Free Program. If you have further questions, please Contact Us.
How did you hear about us?*
Personal Information
Name*

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Date of Birth*

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

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Date
State*
Zip Code*
County*
Today

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Age
Agency ID*
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Baby & Me Tobacco Free Program Self Referral Form

Program Eligibility

Personal Information