COCA Stigma Reduction Campaign I Testimonials
This form is for any Berks County, PA resident who would like to be a part of the upcoming campaign testimonials.

Should you have any questions, contact Jennifer Kirlin at 610-685-4475 or JKirlin@cocaberks.org.

Please provide your full name as you would like it to appear : *
Your answer
Your Phone Number : *
Your answer
Your Email Address: *
Your answer
Do you live or work in Berks County, PA? *
What is your age? (Optional)
Your answer
When you or a loved one were actively using drugs, what was the drug (or drugs) of choice? *
Your answer
When you or a loved one were actively using drugs, how long were you/they using? *
Your answer
How long have you/a loved one been sober or in recovery?
Your answer
What led you/a loved one to get help for substance use disorder? *
Your answer
Did you ever feel or experience judgement due to you or your loved one’s substance use? If yes, please explain. *
Your answer
How did the stigma surrounding addiction affect you? *
Your answer
Have you or a loved one experienced relapse? If so, how did the stigma impact you at that time? *
Your answer
Was the drug NARCAN® ever administered to you or a family member? If so, please describe the situation.
Your answer
Do you feel a negative perception exists surrounding the use and/or administration of NARCAN®? *
Your answer
Since recovery, how has your life changed for the better? *
Your answer
What advice would you give to a person struggling with substance use disorder, afraid to ask for help? *
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service