Quit Kit Order Form - Council on Chemical Abuse | Your Bridge to Addiction Resources

Please fill out the form below to order quit kits for your school or organization. Once we receive the form, someone will contact you to arrange a time to drop off the kits. You may request up to 25 kits. If you need more, please contact Teresa at tdetweiler@cocaberks.org

A Quit Kit is a reusable bag filled with items that you can reach for instead of a cigarette or vape.

2026 Quit Kit Request Form

Please note: We can only provide kits to schools, businesses and organizations in Berks County, PA.

Name(Required)

First Last

Phone(Required)

Email(Required)

Name of organization(Required)

Address where kits will be delivered

Street Address Address Line 2 City State ZIP Code

Please note: We can only provide kits to organizations in Berks County, PA

Which type of kits do you want?(Required)

Adult kits

Youth kits (recommended for schools & colleges)

Both Adult & Youth (you will receive 12-13 of each type)

Please let us know the number of kits you would like us to provide, up to 25. If you need more than 25 please contact Teresa at tdetweiler@cocaberks.org(Required)

Please enter a number from 1 to 25.