Care Form - Community Member

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.

Your Information:

Please provide the following information to ensure CCA can respond and follow up as appropriate. You may choose to submit the form anonymously, however if you choose not to include your name and contact information, there may be limits to the College's ability to adequately investigate or address the situation, or both.

Your Full Name

First, (Preferred), Last

Email Address

Phone

Student Information:

To the best of your ability, provide the following information.

Student Name

First, (Preferred), Last

Additional Names they may go by

Student Email

Student Phone Number

Student CCA ID #

As applicable (ID is either 7 or 8 digits)

Additional Person(s) involved

Include First, (Preferred), and Last Name(s).

Concern Information:

Summary of Concern

To the best of your ability, provide information regarding the concern, incident, or support need(s). Specific details are greatly appreciated.

Supporting Documentation

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 ccacares@cca.edu

This form is official communication with the college and is governed by the Family Educational Rights and Privacy Act (FERPA). By submitting this form, you acknowledge that the information provided is true to the best of your knowledge and will be viewed by the appropriate college officials and responded to accordingly.

I agree

Fields for form variables

SA Type

Contact Information