Non-Profit | Community Organization Contact Form – DEFENT | City of West Hollywood Free Test Device Portal

This form is for non-profit and community-based organizations that are currently funded by the City of West Hollywood and are interested in distributing DEFENT ONE fentanyl testing kits as part of their outreach or harm- reduction efforts.
Please complete the form below in full. A member of the DEFENT program team will follow up with distribution details and available resources for your
organization.
All information submitted through this form is confidential and used only for program coordination purposes.

Application Form

Eligibility (Required)
Is your organization currently funded by the City of West Hollywood?

If yes, provide the Human Services Division Program Administrator’s name

Organization Information (Required)

Organization Name

Primary Contact Name

Title / Role

Phone

Address

Website

Program Details (Required)

Briefly describe your program and how it supports harm reduction in the community

Kit Use (Required)

Distributed to clientsIncluded in outreach kitsUsed for education or training

Other (specify)

Acknowledgment

I confirm that my organization is funded by the City of West Hollywood and that the information provided is accurate.

I understand that all requests are subject to review and approval by the DEFENT program team.