Please complete the following questionnaire to request a free Naloxone (Narcan™) kit. Only patients/family of TCN Behavioral Health, DeCoach Rehabilitation Centre, SafeTrade (syringe exchange program) participants, and Greene County residents/workers are eligible to apply. If none of these apply to you and you are a resident of Ohio, you may order Naloxone through Harm Reduction Ohio.

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* 1. What is your affiliation?

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* 2. Date of Request (note: all requests will be filled each Wednesday and Friday. Please allow 7-10 days to fulfill your request) If you have an immediate need for a naloxone kit, please call contact 937-374-5621 or 937-479-8848 to arrange for a pick up at Greene County Health Department.

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* 3. How old are you?

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* 4. What sex were you assigned at birth, on your original birth certificate? 

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* 5. Do you consider yourself Transgender or Non-Binary? 

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* 6. What race(s)/ethnicities do you consider yourself to be? (Check all that apply)

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* 7. Select the image below to confirm you see it:

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* 8. Items included in kit: 2 doses 4mg Narcan Nasal Spray, 1 Face Shield, 2 Sterile Gloves, 1 Project DAWN informational booklet, 1 Project DAWN carrying bag. **Kits must be kept at room temperature**

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* 9. In which Ohio county do you live? (Please note if you do not live in Ohio)

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* 10. Do you have health insurance? 

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* 11. Intended Use for Naloxone (Check All that Apply):

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* 12. Have you (check all that apply)

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