National 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 up to $250 in rewards like diapers and wipes when you stay 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?*
If either answer is 'No', you are not eligible to enroll in the Baby & Me Tobacco Free Program.
For more information 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*
Should be Empty:

Baby & Me Tobacco Free Program Self Referral Form