Thrive for Change: Application for FREE Harm Reduction Supplies by Mail

What type of supplies are you looking for?*

Syringes and Injection SuppliesGlassware and Smoking Supplies

If you are only looking for naloxone or fentanyl test strips please go to thrive4change.org/ordersupplies.

What drugs have you used in the past 30 days? Select all that apply.*

Please tell us about any barriers you have faced when attempting to access syringes. If you don't inject drugs, type "N/A"*

About how many times per day do you inject?*

How often have you reused your own syringes in the past month?*

How often have you shared syringes with another person in the past month?*

Describe how and where you dispose of your used syringes? Be specific please. If you don't inject drugs, type "N/A"*

Please tell us about any barriers you have faced when attempting to access pipes and glassware. If you don't smoke drugs, type "N/A"*

not for tobacco or cannabis

How many times do you smoke per day? *not including tobacco or cannabis**

How often have you shared smoking supplies / glassware with another person in the past month?*

What is your housing situation?*

Rent or own - Long Term / StableRent or own - Temporary / UnstableLive with family or friends - Long Term / StableLiving with family or friends - Temporary / UnstableHomeless in Shelter SystemHomeless Outside/NOT in Shelter System

Have you overdose in the last 12 months?*

YesNoUnsure

Have you witnessed someone overdose in the last 12 months?*

YesNoUnsure

Have you received testing services for any of the following in the last 6 months?*

Are you connected to and receiving any insurance or public benefits? (select all that apply)*

Is there anything else you want us to know about you, your history, or situation? At Thrive for Change, we believe that everyone deserves to have the supplies they need, however we do have limitations due to staff capacity, funding, and resources.

Thrive for Change: Application for FREE Harm Reduction Supplies by Mail

Application Questions

Final Steps

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Thrive for Change: Application for FREE Harm Reduction Supplies by Mail

Application Questions

Final Steps

ERROR EMAILS DO NOT MATCHPlease re-enter your email and check for typos

ERROR PHONE NUMBERS DO NOT MATCHPlease re-enter your email and check for typos

ERROR EMAILS DO NOT MATCH
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ERROR PHONE NUMBERS DO NOT MATCH
Please re-enter your email and check for typos