UCBA Social Services & Wellness Support Referral Form
Are you completing this referral for yourself or someone else?
On behalf of a student
Please enter a valid phone number.
Student M# (if known)
Reason for referral (mark all that apply)
Navigating college and community resources
Long-term Laptop Lending
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.
Should be Empty: