CAPS Services Request Form

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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.

*CAPS is closed for Winter Break 12/23/2022-1/2/2023 and will resume regular business hours on 1/3/2023. Students will receive calls/emails back as soon as possible following that date.*

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 (follow up email may be sent if unable to make contact via phone)

How can we help you? *

Let's Talk (you are interested in a one-time consultation with a clinician that is *NOT THERAPY*). If this is the case, PLEASE SCHEDULE A SESSION DIRECTLY by visiting caps.sa.ucsb.edu/services/let's-talk

Initial Brief Assessment (you are a student and you would like to initiate services at CAPS)

Returning Client Appointment Request (you are a past or current client and you want to schedule another appointment)

Long-term therapy or Community Referral (you are a student interested in longer term therapy or you are in need of a community referral). For more information, visit: https://caps.sa.ucsb.edu/services/long-term-counseling/community-referral

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. The Distressd Student Protocol can be found here: https://www.sa.ucsb.edu/responding-to-distressed-students/protocol)

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)

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

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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