Nonprofit Harm Reduction Program Intake — Form Fields
This nonprofit template includes 8 fields. Confidential intake form for individuals accessing harm reduction services and supplies. Free to customize and use on ZenBuild.
First Name or Alias (text, required)
Primary Service Requested (dropdown selection, required) — options: Naloxone/Narcan Kit, Syringe Services, Drug Testing Strips, Safe Sex Supplies, Referral to Treatment, Recovery Support, General Information
Zip Code (text, required)
Age Range (dropdown selection, required) — options: Under 18, 18-24, 25-34, 35-44, 45+
Have you visited us before? (dropdown selection, required) — options: Yes, No
How did you hear about us? (dropdown selection, required) — options: Friend/Family, Online Search, Healthcare Provider, Social Services, Other
I understand this service is confidential (checkboxes, required)
Any additional needs or questions? (long text, optional)
