UCBA Social Services & Wellness Support Referral Form

UCBA Social Services & Wellness Support Referral Form
Are you completing this referral for yourself or someone else?

Self referralOn behalf of a student
Name *

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Student Name

First NameLast Name
Student Email
example@example.com
Student M# (if known)
Reason for referral (mark all that apply)*

Academic Support/PlanEmotional SupportFinancial AssistanceFood AssistanceHousing AssistanceNavigating college and community resourcesLong-term Laptop LendingOther
Brief description for referral*
I have also taken the following action(s)*

Submitted a CARE ReportSubmitted a Title IX ReportContacted UC Counseling and Psychological Services (CAPS)Contacted Student's Academic AdvisorProvided Food Pantry InformationOther
If you have not, please submit a CARE report online.
Should be Empty: