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

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.

During this session, the student will complete a brief written survey assignment, then explore their reasons for usage and ways to reduce risk as they learn more about alcohol and cannabis use in a one-on-one session with a professional. 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.

Scheduled by Appointment

Individual sessions (Tier 3) are scheduled by appointment with Health Promotion staff. Please complete the online request form, then instruct students to contact the Substance Abuse Specialist to make an appointment:

Health Promotion

Student Life

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

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

Individual sessions are scheduled by appointment with Health Promotion staff. Please complete the online request form, then instruct students to monitor their UB email addresses, as a Harm Reduction Specialist will reach out to the student to schedule an appointment.

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?

Life on Campus >

New to UB >

Skills for Success >

Here to Career >

Help and Support >

Resources

Find People and Departments

UB Student Experience >

Contact >

Sitemap >

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