Naloxone Order Form

Naloxone Order Form for Community Organizations
Requesting organization’s service area must fall within one or more of the counties in the CMHPSM region. For organizations whose service area falls outside of the CMHPSM region, please visit the Michigan Department of Health and Human Services (MDHHS) MDHHS Online Portal to order naloxone.
County*

LenaweeLivingstonMonroeWashtenaw
Type of Item(s) Needed : CMHPSM provides full naloxone rescue kits and/or kit supplies only. To order naloxone only, please order through the MDHHS Online Portal.
Full Kit (contains one box of Narcan® Nasal Spray, one pair of latex free gloves, one-way valve breathing barrier, instructional brochure, and other items and local resource information as applicable)Kit Supplies Only (Contains one pair of latex free gloves, one-way valve breathing barrier, instructional brochure, and other items and local resource information as applicable. DOES NOT INCLUDE NALOXONE)"Naloxone Available Here" 5 inch x 5 inch window cling (to advertise availability of naloxone at location.)
Please indicate the number of items needed:
Enter Number of Full Kit(s) (Includes all supplies and Naloxone):
Enter Number of Kit Supplies (Includes everything except Naloxone):
Enter Number of "Naloxone Available Here" window clings.
Naloxone received from Community Mental Health Partnership of Southeast Michigan (CMHPSM) is meant to provide additional naloxone capacity.

By checking this box, I affirm that my organization will maintain any existing effort, including financial resources, devoted to naloxone distribution. The naloxone received will be an additional resource and will not substitute for or replace existing resources provided by my organization. I affirm CMHPSM and any outside entities funding the purchase of the naloxone, shall not be liable for any claims related to or arising from the distribution or use of the naloxone provided by CMHPSM.
Affirm
For questions please contact us by email at: naloxone@cmhpsm.org
How did you hear about CMHPSM Naloxone Kits for Community Organizations:
Organization Name:*
Contact Name*

First NameLast Name
Request Date

MonthDayYear
Hour MinutesAM/PM Option
Requester Email*
example@example.com
Requester Phone Number*
Please enter a valid phone number.
Requester Organization*
Type of Organization*
Other, please list:
Is this your first order?

YesNo
At least 2 members of our organization have been trained in a CMHPSM approved Naloxone training program:

Agree
We have read the CMHPSM's Regional Naloxone Overdose Rescue Kit Distribution and Utilization Policy
Agree
Enter Number of Naloxone Only
Pick Up Information:

Please note, CMHPSM no longer offers a delivery option for naloxone requests. All requests must be picked up from the CMHPSM office located at 3005 Boardwalk, Suite 200, Ann Arbor, MI 48108 within one week of receiving notification your order is ready for pick up. Please note, you are able to order naloxone through the MDHHS Online Portal and it will be shipped directly to your organization.
Pick Up or Delivery:

Pick Up from CMHPSM office (3005 Boardwalk, Suite 200, Ann Arbor, MI 48108)Delivery
Date Needed By: (For quantities of 50 or more, please order at least two weeks in advance of date needed.)*

MonthDayYear
Date
Please indicate three potential dates for Pick Up:
Pick up Date Preference Option 1:   Date
Pick up Date Preference Option 2:   Date
Pick up Date Preference Option 3:   Date
Pick Up Time Preference*

9:00am-12:00pm12:00pm-3:00pmOther (Indicate in Text Box Below)
Other Pick Up or Delivery Time Preference
Is Pick Up/Drop Off Name and Contact is the Same as Above

YesNo, please enter pick up contact information below.
Organization Staff who will be Pick Up Order:

First NameLast Name
Email of Organization Staff who will be available for Pick Up:
example@example.com
Phone Number of Organization Staff who will be available for Pick Up:
Please enter a valid phone number.
Delivery Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Delivery Instructions
Naloxone Order Requirements
Distribution

Naloxone/Kits will be used by our organization/trained staff onlyNaloxone/Kits will be distributed to trained community members to use (if selected, an MOU must be on file with CMHPSM, if you do not have an MOU on file or are unsure, please contact Alyssa Tumolo (tumoloa@cmhpsm.org) or Rebecca DuBois (Duboisr@cmhpsm.org) to request one.
Distribution attestation:

Naloxone/Kits will be used by our organization/trained staff onlyNaloxone/Kits will be distributed to trained community members to use (if selected, an MOU must be on file with CMHPSM, if you do not have an MOU on file or are unsure, please contact Alyssa Tumolo (tumoloa@cmhpsm.org) or Rebecca DuBois (Duboisr@cmhpsm.org) to request one.Naloxone/Kits will be used by our organization/trained staff and Naloxone/Kits will be distributed to trained community members to use (if selected, an MOU must be on file with CMHPSM, if you do not have an MOU on file or are unsure, please contact Alyssa Tumolo (tumoloa@cmhpsm.org) or Rebecca DuBois (Duboisr@cmhpsm.org) to request one.
Distribution Attestation

Naloxone kits will only be used internally at our organization by our OEND trained staff.
Naloxone kits will be further distributed by our organizations trained staff to trained community members.Naloxone kits will be used both internally and further distributed by our organizations trained staff.
Organization Distribution Information/Plan

Research suggests that of distributed naloxone kits, approximately 80 – 90 percent of naloxone doses are administered by individuals actively using substances. Furthermore, risk of overdose is highest among certain populations, including:

• individuals who have reduced tolerance of opioids (e.g., after leaving incarceration or abstinence-based treatment; post-partum women who have stopped using; people who have gone through withdrawal)

• individuals using opioids intravenously

• individuals who have previously experienced an opioid overdose

• individuals using opioids with certain other substances

• individuals with opioid use disorder and complex co-occurring medical conditions.
Please describe your organization's plan for distribution, including how your organization will distribute naloxone to individuals at highest risk of overdose (100 words):*
All requests are subject to approval by CMHPSM. Completion of this form does not guarantee that the request will be provided to the organization.

CMHPSM provides naloxone obtained from the MDHHS online naloxone portal. Naloxone provided by CMHPSM and MDHHS is done so under the Naloxone Standing Order. For more information, please refer to 2016-PA-0383.pdf (mi.gov)

Educational Resources can be viewed and downloaded at the following links:
https://www.narcan.com/patients/patient-resources
https://www.narcan.com/first-responders/law-enforcement-roll-call-video
https://beawarebeprepared.com/resources/

If your entity wishes to obtain printed copies of these educational resources and/or demonstration/training devices, please submit a request via email to narcancustomerservice@ebsi.com.
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Naloxone Order Form for Community Organizations

Pick Up Information:

Naloxone Order Requirements