Overdose Reversal Form
If you’ve responded to an opiate overdose using the naloxone sent to you by us or one of our partner organizations, please take a few moments to fill out this form below. Your responses will help us to measure our impact and highlight the importance of a free naloxone program. This will also help us to mail you a refill kit.
Your name is not required. If you responded to more than one overdose (more than one person, date, or location) please fill out one form for each occurrence.
Please reach out to arosser@thrivepeersupport.com if you have any questions.
Where did you receive your narcan from?
Please Select
From our mail program
From one of our partner organizations
From a friend or family member
From an outreach event
What is your relationship to the person who was narcanned?
Please Select
A friend
A family member
A stranger
A client
I experienced the overdose
Prefer not to answer
What county/city did the reversal take place?
Please provide the date the narcan was used:
-
Month
-
Day
Year
Date
How many narcan sprays were used?
1
2
3
4
5+
What race was this person?
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian or Pacific Islander
White
Other
Unknown
Decline to Specify
What ethnicity was this person?
Hispanic or Latino
Not Hispanic or Latino
What age was this person?
Was this the person's first overdose?
Yes
No
I don't know
What substance was the person using?
Was 911 called?
Yes
No
I don't know
Did the person survive?
Yes
No
I don't know
Please fill in any other relevant information that would be helpful for us to know:
Please leave your shipping address so we can send you a new narcan kit.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Would you like us to give you a call to further discuss the overdose?
Yes
No
Would you be interested in signing up for Peer Support services? Having a Peer Supporter can be incredibly helpful for your recovery journey. Leave a phone number for us to call if you would like to discuss this in more detail:
Please enter a valid phone number.
We are always looking for any feedback in our program, if you would like to leave a comment or a review of our services, please do so here. This is confidential and you do not need to leave your name if you choose not to.
Submit
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