EmailMeForm
Request for Naloxone Kit
Naloxone (Narcan) is a medicine that rapidly reverses an opioid overdose. For residents of Berkshire County, we can make a kit available for pickup at our 175 Wahconah St. office .
The kit includes 2 doses of naloxone, instructions for use, fentanyl test strips, and more information on local harm reduction, treatment and recovery services.
Date of Request
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Zip Code of Person Requesting Narcan
Have they previously received naloxone from County Ambulance?
*
Please select
No
Yes
Not sure
Have to previously used naloxone to reverse an overdose?
*
Please select
No
Yes
Prefer not to answer
Gender
Please select
Male
Female
Trans/Non-binary
Other
I prefer not to answer
Age
Please select
Under 18
18 - 34
35 - 54
55 and older
I prefer not to answer
Are you Hispanic or Latino
Please select
Yes
No
I prefer not to answer
Race (check all that apply)
American Indian/Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
More than one race
Other
I prefer not to answer
How did the recipient hear about the distribution?
Newspaper article
Facebook post
Naloxone Distribution Website Map
Other
Preferred method for communicating your naloxone kit is ready for pickup.
Please select
Email
Cell phone text
Telephone call
Email
Phone
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Do you have any questions relating to naloxone, naloxone administration training or an interest in connection to other harm reduction or recovery services?
