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Screening Survey

Screening Form

Thank you for your interest in the First Breath program!

First Breath helps people make positive changes to their tobacco, alcohol, and other substance use during pregnancy and beyond.

Please complete the following questions to see if you are eligible.
1. How did you hear about us?
2. Are you pregnant, postpartum (recently had a baby), or a caregiver to a young child/ren?
3. Have you used tobacco, alcohol, cannabis, illicit substances, and/or misused prescription drugs in the past 90 days?
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