UCBA Social Services & Wellness Support Referral Form
Are you completing this referral for yourself or someone else?
Self referral
On behalf of a student
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Student Name
First Name
Last Name
Student Email
example@example.com
Student M# (if known)
Reason for referral (mark all that apply)
*
Academic Support/Plan
Emotional Support
Financial Assistance
Food Assistance
Housing Assistance
Navigating college and community resources
Long-term Laptop Lending
Care Cabinet Support
Other
Brief description for referral
*
I have also taken the following action(s)
*
Submitted a CARE Report
Submitted a Title IX Report
Contacted UC Counseling and Psychological Services (CAPS)
Contacted Student's Academic Advisor
Provided Food Pantry Information
Other
If you have not, please submit a CARE report online.
Submit
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