Free Naloxone Request Form
Free naloxone kits will be provided to those most at-risk of overdosing on opioids or witnessing an opioid overdose. If you do not frequently come in contact with an individual using opioids, please consider purchasing naloxone from your pharmacy. It is covered by most insurance plans at a discounted rate.
Please fill out the form below accurately and truthfully to the best of your ability. If determined to be eligible, you will get a confirmation email and your free naloxone kit will be mailed to the address provided.
If you end up using your emergency naloxone, please return to our website to self-report. Self-reporting naloxone use will provide crucial data that will help ensure recovery and rehabilitation services in your area, as well as the availability of lifesaving medicines like naloxone in your region.