Share your story

Die Datei kann in Ihrem Browser nicht geöffnet werden, weil JavaScript nicht aktiviert ist. Aktivieren Sie JavaScript und laden Sie die Seite noch einmal.

Share your story

Tell us how heroin or opioid addiction affects your life and what you wish others knew about addiction.

In Google anmelden, um den Fortschritt zu speichern. Weitere Informationen

What role does heroin or opioid addiction play in your life? *

Check all that apply.

I'm a current or former heroin or opioid user

I'm a friend or family member of someone who abuses heroin or opiods

I provide treatment for those addicted to heroin or opioids

Sonstiges:

Pflichtfrage

What do you wish people understood about heroin or opioid addiction? *

How can we contact you?

Please leave an email address or phone number in case we'd like to follow up. This will always be kept private.

Your name

Optional. We can keep your story anonymous if you'd like, or include part of your name.

Your home city

Optional. Please include your state, too (ie Springfield, Mass.)

How would you like your story shared? *

Make it public, including my first name

Make my story public, but keep my name private

Share it with FRONTLINE reporters, but otherwise please keep it private

By using this form, you agree that we can use your submission in all manner and media and that we shall have the right to authorize third parties to do so. You also agree that what you post is original and your own.

Senden

Alle Eingaben löschen

Gib niemals Passwörter über Google Formulare weiter.

Google Formulare

Dieser Inhalt wurde nicht von Google erstellt und wird von Google auch nicht unterstützt.