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? *
Email Address *
What is your preferred form of communication for our follow up? *
How can we help you? *
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.)
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. *
Required
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