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2. Craven County Opioid Epidemic Response Naloxone Request Form

   
   

   If the submit form button does not work, please email the request form to katelyn.godley@cravencountync.gov to ensure the form is received.

   Naloxone distributed through this form is meant to provide additional Naloxone capacity, beyond existing efforts through municipal, non-profit, and private organizations within Craven County that serve people who are at risk of experiencing or witnessing an opioid overdose. Once submitted, you will be notified when the kits are available for pickup or delivery. Details and directions will be included in the notification. 

   Naloxone administration and overdose response education will be provided to community organizations receiving Naloxone as required by the Craven County Opioid Epidemic Response standing order. 

4. Agency Name
5. Contact Person Name
7. Email Address
9. Agency Address
11. City
12. Zip Code
13. Phone Number
15. Type of Organizaton
    -- Select One --Community Mental Health Center/Certified Community Behavioral Health OrganizationCommunity OrganizationEMSFire DepartmentHarm Reduction Program/Mobile OutreachLaw Enforcement Other Recovery Housing SUD Treatment Provider
16. Training Needed
    -- Select One --YesNo
18. Number of Narcan Units Requested (2 doses per unit)
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field