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Note: We are only able to assist with requests within Arizona, but we’re happy to refer you to resources nearer to you if that would be helpful.
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Name *
You do not have to give us your legal or real name, but we need a name to address your package to.
Race/Ethnicity *
Check all that apply
Required
Gender Identity *
Required
Age *
Sexual Orientation
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Street address *
Please include P.O. Box and/or full street address with Number, Street Name, Street Suffix, and Apt or House # if applicable.
City *
State *
Zip Code *
How many naloxone kits are you requesting? *
Have you received naloxone from Sonoran Prevention Works before? *
Have you ever used Naloxone from SPW to reverse an overdose? *
How many people besides yourself are you requesting naloxone for?
Phone number
Please use XXX-XXX-XXXX format if possible. We will only use your phone number to update you on supply availability and shipping info.
If you provided us with a phone number, can we text you?
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Are you a requesting a kit as a (choose only one): *
Is there anything else you would like support with?
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