Program Eligibility
Is the pregnant woman 36 weeks gestation or less?
Please select...
Yes
No
Is the pregnant woman a current tobacco user, quit since becoming pregnant, or quit within 3 months of becoming pregnant?
Please select...
Yes
No
If either answer is 'No', she is not eligible to enroll in the BABY & ME-Tobacco Free Program.
For more information please
Contact Us
.
Client Information
First Name
Last Name
Date of Birth
Email
Phone
Estimated Due Date
ZIP Code
County
Please select...
Benton
Coos
Curry
Jackson
Josephine
Linn
Does this client require Spanish translation services?
Please select...
Yes
No
Mailing Address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Referring Organization
Agency Type (Check all that apply)
Community Health Center
Health Department
Hospital/Birthing Center
Insurance Provider
Physician's Office
Quitline
WIC
Other
Agency Type
Complete if you picked Other above
Agency Name
Agency Address
Agency City
Agency State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Agency ZIP Code
Agency County
Please select...
Benton
Coos
Curry
Jackson
Josephine
Linn
Agency Contact Name
Agency Contact Phone
Agency Contact Email
Please attest and check the box below:
I attest that the information provided by me in this referral (i.e.- client eligibility, client information, and agency information) is correct, accurate, and complete.
Please acknowledge and check the box below:
I acknowledge that the client being referred consents to having their personal information shared with the National BABY & ME-Tobacco Free Program and their referral status communicated back to me.
Please acknowledge and check the box below:
I acknowledge that the client consents to being contacted as part of this referral prior to enrollment by the National BABY & ME-Tobacco Free Program via phone call, voice message, and/or email at the contact information listed above.
Additional Notes