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Online Narcan Training Completion and Request Form

  1. THANK YOU for watching the Narcan training video!

    Through its Opioid Overdose Prevention Program, the Cayuga County Community Mental Health Center is able to offer a free Narcan kit to residents who complete the online training video and submit the form below.

  2. To receive your FREE NARCAN KIT, please enter your name and mailing address.
    Your information is strictly confidential and will not be shared with third parties.
  3. Enter your email address to receive periodic information about local addiction and recovery resources. Your information will not be shared with third parties.
  4. Please check the box if you would like to be contacted by a recovery peer advocate.

    Peers engage and connect individuals to local services by utilizing their recovery expertise, professional training, and lived experience.

  5. Please indicate how you would like to be contacted by a peer (phone number, email).
  6. Tell us about your MOTIVATION to take this training. Why did you wish to learn more about Narcan? (multiple answers possible)*
  7. Have you ever witnessed an overdose? (multiple answers possible)*
  8. Tell us about YOURSELF. What is your gender?*

    Your information will not be shared with third parties and will be used for statistical purposes only.

  9. How would you describe yourself?*
  10. Are you a first responder?*
  11. Do you work with people in the areas of mental health, addiction, or recovery?*
  12. How did you hear about this online training?*

    More than one answer can be selected:

  13. Thank you for your time and willingness to learn about Narcan!
    Be on the lookout for your free Narcan kit in the mail.
  14. Leave This Blank:

  15. This field is not part of the form submission.