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INDIANA NALOXONE REQUEST AND REPORT

Naloxone available through NEW partnership with the State of Indiana

report

OVERDOSE REVERSAL REPORTING

What option best describes you?
Have you participated in the Recovery Capital Index?

Please select the approximate date that the overdose occurred

Who Overdosed?

Please indicate the approximate age of the person who overdosed

What was their gender?
What was their race or ethnicity?
What setting did it occur in?
What was the result of the overdose?

The information provided through this form is solely viewed by SafeHaven Freedom Ministry Staff. The only information shared by SafeHaven Freedom Ministries is the total number of overdose reversal reports that are submitted each month.

Request

NALOXONE & FENTANYL STRIPS REQUEST

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Thanks for submitting, place your order and we will be in touch!

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