CIC Mental Health Financial Assistance Referral
Campus partners, please complete this form if you would like to refer a student to CIC for our financial assistance program. The financial assistance is capped at $500 per student and allows them an opportunity to obtain mental health services in the community, with direct payment made to the providers. Participating in the financial assistance program will require the student to submit basic demographic information to CAPS and CIC, as well as a Release of Information, kept on file for coordination of care (payments).
PRIOR TO SUBMISSION OF REFERRAL, PLEASE REVIEW ALL FUNDING GUIDELINES AT: https://cic.charlotte.edu/referrals/referral-funding. After submitting the referral, please contact 
Leigh Norwood, LCSW at leigh.norwood@charlotte.edu or Aayla Alexander, LCSW at aalexa48@charlotte.edu so that we may contact the student directly. Thank you!
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Email *
Faculty/Staff Name *
Department/Unit *
Student is AWARE and HAS CONSENTED to this referral on their behalf *
Student is currently ENROLLED and to your knowledge is in good standing. *
Student is AWARE and HAS CONSENTED to follow-up from the Center for Integrated Care, via the phone # or email provided. *
Student ID# *
Student Name *
Phone # *
Email *
Financial assistance is being requested to cover (check all that apply) *
Required
Have you and the student reviewed the funding guidelines (https://cic.charlotte.edu/referrals/referral-funding) prior to submission of this form? *
A copy of your responses will be emailed to the address you provided.
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