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.

PERM# (if you are a UCSB student)

Phone Number *

May we leave a voicemail if you are unable to pick up the phone? *

Yes

Email Address *

What is your preferred form of communication for our follow up? *

Phone Call/Voicemail

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 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/group-counseling-program---fall-2020 & 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) *

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

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