Referral Questionnaire- List Only *Please note: This information is not reviewed by CAPS staff until a later date. Name First Last UIN Email 1. What type of community service(s)/resource(s) are you in need of? Please check all that apply. Counseling Psychiatry Formal Psychological Evaluation (including cognitive, personality, or other forms of testing) Learning disability/ADD/ADHD Evaluation Medical/health care Food assistance Housing 2. I have access to transportation. Yes No 3. I have health insurance. Yes No 4. If answered 'yes' to the above statement, please specify the name of your insurance company (i.e., BCBS, Aetna, Cigna, etc.). 5. I would like resources that offer a sliding scale cost (i.e., based off of income) and/or are free. Yes No Zip code where services are needed. 7. Please select all that apply. I would like in-person mental health support/resources. I would like virtual mental health support/resources. 8. To assist with identifying resources, please select your primary concerns for provider services. Please check all that apply. Abuse/violence Academic issues Addiction (behavioral/substance) ADD/ADHD/Attention problems Anger Anxiety Autism Spectrum Bipolar disorder Career concerns Chronic illness Cultural concerns Depression Disability Family conflict Food assistance Eating concerns Grief/bereavement HIV/AIDS Housing Interpersonal skills Learning disability LGBTQ+ concerns Life transitions Marital/pre-marital Medical/health care Men's issues Obsessive Compulsive Disorder Pain management Parenting Personality disorder Pregnancy, prenatal, postpartum PTSD/trauma Racial identity Relationship issues Schizophrenia Self-esteem Sexual issues Weight loss Women's issues 9. Of the concerns you selected, please identify your top 3 in the space below. 10. If you have any specific counselor preferences, please specify below (Ex: “I prefer a provider that is male-identified,” “… that is LGBTQ+ friendly,” “… that is a person of color,” “… that providers religious counseling,” etc.). **Please note, your preferences may or may not be available.11. Please note any language preferences you may have.