UB SAFER Referral and Registration Form

Refer a student — or register yourself — for the UB SAFER intervention program. You can use this form for Tier 1, Tier 2 or Tier 3 sessions.

Timeliness is important. We cannot admit anyone after the group session begins.

Please leave blank

Student Personal Information

Name

(Required)

Phone Number

(Required)

Referral Information

Please explain, if other reason was selected

Referred By (Contact Person)

(Required)

Referral Email Addressee (Contact Person)

(Required)

Date of Violation

(Required)

Other (Please explain if Other was selected)

Select a Class

During this session, students will examine their alcohol and/or cannabis use, review tips for reducing risks related to substance use, explore how to be a helpful bystander in these situations and affirm positive strategies that they are already using.

During this session, students will complete a brief written assignment, then explore their reasons for usage and ways to reduce risk as they learn more about alcohol and cannabis use; through self-reflection and goal setting, students have the opportunity to explore alternatives to their behavior in order to decrease negative consequences related to alcohol and other drug use.

Attention Staff

Please note the new additional step below for Tier 3 referrals

Scheduled by Appointment

Individual sessions are scheduled by appointment with Health Promotion staff. Please have students visit the link below to make an appointment for their Tier 3 at a time that works best for them.

Students: Click here to make your Tier 3 appointment

Please then enter the time and date of their appointment in the text box below:

Additional Appointment Detail (time and date)

Security Check

(Required)

Need Help Completing the Form?

Health Promotion

Student Life

University at Buffalo
114 Student Union, North Campus
Buffalo, NY 14260

Phone: 716-645-2837; Fax: 716-645-6234

UB SAFER Referral and Registration Form

Student Personal Information

Referral Information

Select a Class

Scheduled by Appointment

Need Help Completing the Form?

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UB SAFER Referral and Registration Form

Student Personal Information

Referral Information

Select a Class

Tier 1 - An In-Person Class for Lower-Risk Alcohol and Other Drug Use

Tier 2 - An In-Person Class for Moderate-Risk Alcohol and Other Drug Use

Tier 3 - An Individual Session with a Health Promotion Harm Reduction Specialist

Scheduled by Appointment

Need Help Completing the Form?

Resources

Find People and Departments