NARCAN Request Form

NARCAN (naloxone HCl) Nasal Spray is an FDA-approved medication used to treat known or suspected opioid overdose. Our goal is to get as many doses as possible directly into the hands of community members who are actively using, or friends and family of active users in Monett, Neosho, and surrounding areas.

Which of the following best describes you?

I am in active addiction/using opioids or street drugsI have a friend or family member in addiction or who is using opioids or street drugsI am a caseworker or professional with clients who face substance abuse issuesOther

Why do we ask? Information will be used to assess needs, coordinate delivery, and help maintain access to future supply. Community members are not required to share any identifying information.

Please describe why you are requesting NARCAN and how you will get it into the hands of those who need it.

Please provide as much information below as you feel comfortable sharing. Feel free to use initials or a pseudonym if you do not want to provide your real name. All demographic information will be used for tracking purposes and to help secure future supply. Our goal is to get this medication into hands that may need it; you are not required to share any personal information in order to make a request. Please provide at least one method for us to contact you to make arrangements to pick up or drop off.

Name

First NameLast Name

Agency or Organization

Job Title or Role

Email

example@example.com

Phone Number

Please enter a valid phone number.

Location (City or Town)

Age or Approximate Age

Gender

Ethnicity