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Safe Harbor Referral Form

Safe Harbor offers free and confidential support for Auburn University students and employees who have experienced any form of sexual or interpersonal violence. Use this form to refer yourself or someone you know to speak with a Safe Harbor advocate. A Safe Harbor advocate will contact the survivor within 24 hours on a business day after receiving this form to provide support and offer to schedule a meeting. Email safeharbor@auburn.edu if you have any questions.

Referring Source Information

Full Name:

Auburn Affiliation:

Learn more

(Faculty, Staff, Student, Family Member)

Phone Number:

Email Address:

Email address must be of a valid format.

Your physical address:

Time of incident:

Specific location:

Survivor/Victim Information

Involved party 1

Full Name:

Banner ID Number:

Phone number:

Email address:

Nature of Concern?

Sexual Assault Sexual Harassment Stalking Dating/Domestic Violence Drugging Threat Prefer not to disclose Other

You must make at least one selection.

Please provide any additional details or information that can assist Safe Harbor with supporting this individual: This field is required.

How would you like us to contact this individual?

Email Phone Call Text Message Unsure (Contact Me to Discuss)

You must make at least one selection.

Have your reported this to the Title IX Office?

Yes No

This field is required.

Does this individual know that you are making this referral?

Yes No

This field is required.

Submission

Email me a copy of this report