Wilmington LEAD Referral - NC Harm Reduction Coalition

Wilmington LEAD Participant Referral

This form is for LEO and First Responders in New Hanover County that need to make a referral to the North Carolina Harm Reduction Coalition for post overdose follow up, overdose prevention intervention, or the Law Enforcement Assisted Diversion (LEAD) Program.

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Name

First Last

Date

Department or Agency

Any Related Incident #

Participant Name

Participants Date of Birth

Participants Email Address

Participants Phone Number

Participant's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

If unsheltered please include a location where we can make contact.

Sex or Orientation

Male

Female

Trans

Race

Caucasian

Black

Native Indigenous

Asian/Pacific Islander

multi-racial

Latin/Hispanic

Reason for referral

Type of Referral

In order to participate in LEAD, the participant must sign a medical release of information so that the LEAD Case Coordinating Team staff their program.

Are they still interested in participating in LEAD?

If No, why?

File

Max. file size: 128 MB.

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Wilmington LEAD Participant Referral

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