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Medina County Opiate Response Team
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Medina County's 24/7 Crisis & Behavioral Health Helpline (330) 725-9195
Opiate Response Team Referral Form
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Name of Person Making Referral:
*
Police Department:
*
Client First Name:
*
Client Last Name:
Date of Birth:
Address:
City:
State:
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Zip Code:
Phone:
Family/ Significant Other Information:
Family/ Significant Other Phone:
Date of Overdose:
Location of Overdose:
*
Was immunity letter given to client?:
-- Select One --
Yes
No
Other Information:
*
Security Key: