National Referral Form

Baby & Me Tobacco Free Program Referral Form
Program Eligibility
Is the client pregnant and 36 weeks gestation or less?*
Does the client currently use tobacco/vaped nicotine/any form of nicotine, quit since becoming pregnant, or quit within 3 months of becoming pregnant?*
You indicated that the client currently uses or has previously used tobacco/nicotine but is not pregnant. Because of this, they are not eligible to enroll in the Baby & Me – Tobacco Free Program. We encourage you to refer them to 1-800-QUIT-NOW for additional support and resources.
Based on the information provided, the client is not eligible to enroll in the Baby & Me Tobacco Free Program. If you have further questions, please Contact Us.
Client Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email*
If not applicable, please enter noemail@gmail.com
Estimated Due Date*

MonthDayYear
Date
Zip Code*
Does this client require Spanish translation services?*
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Referring Organization Information
Agency Type*
Agency Type (Other)
Complete if you picked Other above
Agency Name*
Agency Address*

Street Address

Street Address Line 2

CityState

Zip Code
Agency Contact Name*
Agency Contact Phone Number*
Please enter a valid phone number.
Agency Contact Email*
example@example.com
Additional Notes
Client Identifier Number (if applicable)
Today

MonthDayYear
Date
Age
Agency ID*
Agency Type (OLD)

Community Health CenterHealth DepartmentHospital/Birthing CenterInsurance ProviderPhysician's OfficeQuitlineWICOther
Should be Empty:

Baby & Me Tobacco Free Program Referral Form

Program Eligibility

Client Information

Referring Organization Information