Indiana 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?*
Does the client reside in Miami or Scott County, Indiana?*
You indicated that the client currently uses or has previously used tobacco/nicotine but is not pregnant or does not reside in Miami/Scott County. Because of this, they are not eligible to enroll in the Baby & Me – Tobacco Free Program. We encourage you to refer them to Quit Now Indiana 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*
example@example.com
Estimated Due Date*

MonthDayYear
Date
Zip Code*
County*
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 County*
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