Care Form - Staff & Faculty

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DO NOT report an emergency in this form. If this is an emergency call 9-1-1 and then call CCA Public Safety at 415.703.9510. If this is a psychological emergency, please contact CCA’s Mental Health Crisis Hotline at 510.594.5099. 

After submitting the form, you will receive a confirmation email. This information will be reviewed within 3 business days. You can expect a delayed response during college closures. 

Area of Concern:

Your Information:

Please provide the following information to ensure CCA can respond and follow up as appropriate. 

First, (Preferred), Last

Student Information:

To the best of your ability, provide the following information regarding person(s) involved.

First, (Preferred), Last

As applicable (ID is either 7 or 8 digits)

List additional person(s) involved if applicable. Include First, (Preferred), and Last Name(s) and any contact information available.

Concern Information:

What was the approximate date/time when the concern began

To the best of your ability, provide information regarding the concern, incident, or support need(s). Specific details are greatly appreciated, including duration of concern (if applicable.) Include specific behaviors and facts.

Have you or another person addressed the concern with the student? Please describe and include any referrals to campus resources already provided.

Please attach files here. You can upload up to three files. To upload more than three files, please add them to a single zip file before uploading. This form can not be used to upload video files. Please email video files to

Fields for form variables