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
Other
Brief description for referral
*
I have also taken the following action(s)
*
Submitted a CARE Report
Emailed student information about counseling
Contacted UC Counseling and Psychological Services (CAPS)
Contacted student's academic advisor
Contacted the food pantry
Contacted Title IX
No other action has been taken at this time
If you have not, please submit a CARE report online.
Submit
Should be Empty: