Quick Response Team Referral Form
Use this form to refer someone you know (or yourself) to a local Health Department's Quick Response Team. These teams specifically visit the residences of individuals living in the South Shore (Cudahy, Oak Creek, South Milwaukee, or St. Francis) who use substances or who have had a recent nonfatal overdose and may be looking for treatment or harm reduction resources.
Please note that completing this form does not guarantee a visit from the QRT team. Visits occur as capacity allows. Your response is confidential.
Are you completing this form for yourself or on behalf of someone else?
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Myself
Someone else
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Please enter the first and last name of the individual you are referring
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Please enter this individual's address including the city in which they live
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Please enter this individual's phone number (if known)
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What is your first and last name?
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Is the individual aware of your referral?
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Yes
No
Please select their primary language
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English
Spanish
Arabic
Hmong
Other
Which of the following resources do you think would be helpful to them?
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Narcan (naloxone)
Medication disposal bags
Fentanyl test strips
Treatment options
Other
Use this space to provide more information to the QRT. Including your relationship to the individual and your reasoning for referring them.
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Please enter your first and last name
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Please enter your address including the city in which you live
*
Please enter your phone number
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Please select your primary language
*
English
Spanish
Arabic
Hmong
Other
Which of the following resources would be helpful to you?
Narcan (naloxone)
Medication disposal bags
Fentanyl test strips
Treatment options
Other
Use this space to provide more information to the QRT. Including your reasoning for completing this referral form.
Back
Next
Thank you for your response. Please click submit below.
Submit
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