Syringe Exchange Visit Form Syringe Exchange FormInitials(Required)Last 4 of SSN or Employee ID(Required)Is this your first time at the Exchange?(Required) Yes No Prefer Not To AnswerSite(Required)Community EventLGBT CenterMobile Mead HouseMobile Neighborhood PetsThe Centers - EastThe Centers - Gordon SquareThe Centers - UptownThe Centers - WestMobile UnitCounty(Required) Cuyahoga Lorain Geauga Summit Lake Medina Portage OtherMore InfoWhat drugs do you inject?(Required) Cocaine Crystal Meth Fentanyl Heroin Ketamine Pills Xylazine NoneSelect AllWhat drugs do you use?(Required) Alcohol Central Nervous System Depressants (Benzos) Cannabis (Marijuana/Pot/Weed) Cocaine (Crack/Coke) Fentanyl Hallucinogens Inhalants Ketamine LSD (Acid) Psylocibin (Magic Mushrooms/Shrooms) MDMA (Ecstacy/Molly) Methamphetamines (Crystal/Meth) Other-the-Counter Medications (other) PCP (Angel Dust) Prescription Opioids (Oxy/Percs) Prescription Stimulants (Speed) Synthetic Cannabinoids (K2/Spice) Synthetic Cathinones (Bath Salts/Flakka) Xylazine NoneSelect AllDo you use any of the following routes to use your drugs? Intranasal (snorting) Anal ('booty bumping') Oral (swallow) None of theseSelect AllCheck all that apply.Have you overdosed in the last 6 months?(Required) Yes NoDo you have a naloxone (Narcan) kit?(Required) Yes NoDid you go to the Emergency Department? (ED)(Required) Yes NoWould you like to recieve naloxone (Narcan) today?(Required) Yes NoHow many naloxone (Narcan) kits would you like today?(Required)Order FormSupplies Needed(Required) Alcohol Wipes Bandages Bleach Bubbler Smoking Kit Condoms Cooker Cotton/Filter Fitpack Sharps Container Lubricant Ointment QuickPack Feminine Hygiene (BNRC) QuickPack Personal Hygiene (BNRC) QuickPack Food (BNRC) Safer Sex Kit SSP Hygiene Kit Stem Smoking Kit Tourniquet Water Wound Care Kit No supplies givenHow many alcohol wipes?(Required)How many bandages?(Required)How many bleach?(Required)How many condoms?(Required)How many cookers?(Required)How many Cotton/Filler?(Required)How many Fitpak Sharps Containers?(Required)How many lubricant?(Required)How many ointment?(Required)How many QuickPack Feminine Hygiene?(Required)How many QuickPack Personal Hygiene?(Required)How many QuickPack Food?(Required)How many Safer Sex Kits?(Required)How many SSP Hygiene Kits?(Required)How many Stem Smoking Kits?(Required)How many tourniquets?(Required)How many water?(Required)How many wound care kits?(Required)BNRC Required DemographicsBirthdate(Required)Race(Required)American Indian/Alaskan NativeAsianBlackHispanic/LatinoMulti-RacialNative Hawaiian/Pacific IslanderWhitePrefer not to answerEthnicity(Required)HispanicNon-HispanicPrefer not to answerSex Assigned at Birth(Required)MaleFemalePrefer not to answerCurrent Gender(Required)FemaleIntersexMaleNon-BinaryTransgenderPrefer not to answerAre you pregnant? Yes No Unknown Prefer Not to AnswerOther ServicesAre you interested in learning about other services? Abscess Treatment Basic Needs (clothing, etc.) Behavioral Health Benefits Dental Detox El Barrio Emergency Department Food Security HIV Screening/HIV Counseling HCV Screening/HCV Treatment Hep A/B Screening & Vaccines Housing/Shelter Assistance Infectious Disease (i.e., HIV, Hep C) Inpatient Treatment IPV/DV Referral MAT Medical insurance enrollment Narcan/Project Dawn Outpatient Treatment Peer Support PEP PreP Pregnancy Screening/Prenatal Care Primary Care Other No other referral