SAFE Online Diversion Program Referral

Complete this form to enroll a student in SAFE's Up in Smoke online course, a free substance use diversion program. This worksheet is available to help you gather information needed for completing the registration form: https://tinyurl.com/uiswksht

Student must

Be referred by a school teacher, administrator, or counselor, or a guardian
Be between the ages of 14–18
Commit to completing the online course in one, 6-hour day (the course may be started at any time)
Live in Massachusetts

Questions? Contact SAFE at info@safecoalitionma.org or (508) 488-8105

Referent's first name

Referent's last name

Referent's email address

Student's first name

Student's last name

Student's preferred name

Student's personal pronouns

Student's school

Student's phone

Student's email

Student's date of birth

Month

Day

Year

Student's residential street address (include apt., etc.)

Student's town

Student's zip code

Language spoken at home

Guardian's first name

Guardian's last name

Guardian's email address

Guardian's phone number

Does this student have a history of mental health diagnoses?

Yes

I'm not sure

Why are you referring this student for SAFE's online diversion program?

Does this student have a 504 or IEP plan?

Yes

I'm not sure

Anything else we should know?

Would you like to join the SAFE mailing list?

Yes

How did you hear about this program?