Care Form - Community Member

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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. 

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.

First, (Preferred), Last

Student Information:

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

First, (Preferred), Last

As applicable (ID is either 7 or 8 digits)

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

Concern Information:

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

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

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