CAPS Services Request Form
Please note that these form submissions are NOT monitored 24/7. If you need immediate mental health support, please call (805) 893-4411 and press 2 to speak with a live counselor. If this is a situation that involves potential harm to self or others, please call 911 immediately.
Submissions will be reviewed during CAPS business hours -
http://caps.sa.ucsb.edu/about-us/contact-us-hours-location
.
* Required
PERM# (if you are a UCSB student)
Your answer
Phone Number
*
Your answer
May we leave a voicemail if you are unable to pick up the phone?
*
Yes
No
Email Address
*
Your answer
What is your preferred form of communication for our follow up?
*
Phone Call/Voicemail (follow up email may be sent if unable to make contact via phone)
Email
How can we help you?
*
Initial Brief Assessment (you are a student and you would like to start CAPS services)
Returning Client Appointment Request (you are a past or current client and you want to schedule another appointment)
General Question (you would like a call-back from CAPS to get general information)
Concerned About Someone? (you are a student, parent, staff/faculty, community member worried about a student. If this is an emergency, please call 911. Also, please connect with Student Mental Health Coordination Services by filling out this form:
ww.sa.ucsb.edu/REFERaGAUCHO
or calling (805) 893-3030)
Group Counseling Pre-Screen (you have reviewed
https://caps.sa.ucsb.edu/services/group-counseling
& have submitted an interest form)
If you selected Group Counseling Pre-Screen, which group(s) have you submitted an interest form for? (if not interested in Groups, please skip this question)
Your answer
If you selected Returning Client Appointment Request, would you like to see the same therapist you have seen most recently? Therapist availability will be based on a variety of factors but your response will help our administrative and clinical teams review these appointment requests. (If you are not a returning client, please skip this question or mark N/A.)
Yes
No
Unsure
Not Applicable (N/A)
Clear selection
By checking this box, you acknowledge that you understand that this request form is NOT monitored 24/7 and that you will seek out emergency services if you are in a situation that could involve harm to self or others.
*
I understand
Required
Submit
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