COCA Stigma Reduction Campaign I Testimonials

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This form is for any Berks County, PA resident who would like to be a part of the upcoming campaign testimonials.

Should you have any questions, contact Jennifer Kirlin at 610-685-4475 or JKirlin@cocaberks.org.

Please provide your full name as you would like it to appear : *

Your Phone Number : *

Your Email Address: *

Do you live or work in Berks County, PA? *

Yes

Other:

What is your age? (Optional)

Are you open to being video-taped to discuss your testimonial? All submitted testimonials will be used in web posts and printed materials. *

Yes

Maybe

When you or a loved one were actively using drugs, what was the drug (or drugs) of choice? *

When you or a loved one were actively using drugs, how long were you/they using? *

How long have you/a loved one been sober or in recovery?

What led you/a loved one to get help for substance use disorder? *

Did you ever feel or experience judgement due to you or your loved one’s substance use? If yes, please explain. *

How did the stigma surrounding addiction affect you? *

Have you or a loved one experienced relapse? If so, how did the stigma impact you at that time? *

Was the drug NARCAN® ever administered to you or a family member? If so, please describe the situation and if you are comfortable sharing about this on video.

Do you feel a negative perception exists surrounding the use and/or administration of NARCAN®? *

Since recovery, how has your life changed for the better? *

What advice would you give to a person struggling with substance use disorder, afraid to ask for help? *

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