Peer Counseling Referral Form

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Peer Counseling is a peer-to-peer program at the University of Arizona that offers Psychological First Aid (PFA) to students in a confidential and safe environment (see: https://caps.arizona.edu/peer-counseling). We offer free identity-based groups and one-on-one student check-ins. To refer yourself, or someone else, for one-on-one student check-in, please fill out this form.

NOTE: This is not psychological treatment but rather a supportive intervention to help students connect and share tools to cope with stress. Peer Counselors will seek guidance from professional health and wellness staff on how best to support students who may be in danger of self-harm or harm to others to access appropriate levels of care beyond psychological first aid.

IF YOU ARE EXPERIENCING AN EMERGENCY, PLEASE CONTACT CAPS AT 520-621-3334, DIAL 911, OR GO TO YOUR LOCAL EMERGENCY ROOM

Reporter's Full Name

Phone Number

Are you referring yourself or someone else?

If referring someone other than yourself, please fill out the following information to the best of your ability.

Full Name

Phone Number

Please check the box if you (reporter) would prefer to remain anonymous:

If you are comfortable, please use the space below to provide more detail:

If you are contacting us about a specific incident, please enter the date and time of that incident.

If time is unknown, please select 00:00