Public CARE Report

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Gaucho Support & Outreach Referral Form

Please provide as much detail as you can on the referral form below. If you prefer to discuss this referral with a coordinator, you may call SMHCS at 805-893-3030.

AcknowledgementRequired

By checking this box, I acknowledge that if there is an immediate threat to self/others related to this report, I have already contacted the University of California Santa Barbara Police Department (UCPD) to report it and will continue filling out this form as a way to notify the University.

Please list your name, phone, email, etc.

For faculty and staff only.

Please provide first and last name of the student for whom you are concerned.

Please include student ID (PERM) number, if available. This ensures that we are looking at the correct student.

Please include any contact information you have for the student, i.e. email, phone number, current address.

Please provide name(s), address(es), phone number(s), and email(s) of other involved parties.

What was the approximate date/time when the behavior became concerning.
   

If referencing a specific incident, where did this situation occur?

Please provide a detailed description of events and concerns, including student name(s), specific date(s), and location(s).

Use concise and objective terms to describe your interactions and the specific behaviors you observed; please avoid documenting subjective interpretations of behavior, or motives for behavior in the description.

Level of ConcernRequired

What is your current level of concern for, or about, this student? Please select one option.

Have you or someone in your department addressed the issue/behavior of concern with the student? If yes, what did you do?

Referrals

Have you referred the student to any campus resources? Please check all that apply.

Please list other departments/resources where student was referred.

Attach Documents/Upload

Please attach any documents or emails relevant to the referral.

Please enter the verification code that appears below. Click the link below the image to hear the code read aloud.