Test - SRHN

TESTING FUNCTIONS Mailed Naloxone Kit Request Form

"*" indicates required fields

Please confirm that you cannot pickup a kit from a NAP, or there are no NAP sites in your area*

I confirm that pickup is not an option for me.

* We have over 40 naloxone pickup sites in the metro area! If possible, please consider visiting one of these locations for faster, same-day access.

Name*

First Last

This will help SRHN contact you if there are issues fulfilling your request, but is not required.

Are You Able to Donate to Help Cover Postage?

SRHN is nonprofit; any and all donations help to continue these services for all MN residents!

$3 Twin Cities Metro | $5 Statewide | $10 Pay-It-Forward

Yes

Address*

Please provide an address.

Street Address Address Line 2 City State ZIP Code

Greater Minnesota Mailer Program Eligibility

Ramsey County Mailer Program Eligibility

Ramsey County Program

Ramsey County is offering additional naloxone support. Your responses are confidential and helps us distribute resources where they’re most needed.

Program Eligibility

SRHN is currently able to offer nasal kits in your area. Please let us know your preference.

I would like a nasal kit

I would like an intramuscular (IM) kit

Program Eligibility (Ramsey County)*

Are you, or someone you know, at risk of experiencing or witnessing an overdose?

Yes

Program Eligibility (Training)*

Have you ever taken a naloxone training before?

Yes

Racial/Ethnic Identity

To receive a nasal naloxone kit from Ramsey County Public Health, you must complete a naloxone training. Please choose one of the available options below:

If you would prefer to receive an intramuscular (IM) naloxone kit today without completing a training, please change your selection above and submit this form.