fee waiver request form

University of California, Santa Barbara

Counseling and Psychological Services

To request a fee waiver, please fill out the following form completely, legibly and concisely. Your request will be reviewed by

management. Please submit the form within 10 business days of the late cancellation or missed appointment.

Name:

Appointment Date:

Phone:

PLEASE COMPLETE AND SUBMIT THE FEE WAIVER FORM TO:

FEE WAIVER REQUEST FORM

PERM: E-mail:

You will be notified once a decision has been made on your request.

Please allow up to 15 business days for processing

Late Cancellation

Type of Fee to be Waived:

Missed Appointment

Appointment Time:

Clinician:

As clearly and concisely as possible, please explain why you would like to have your fee waived:

(If you need more room, please use the back of this form)

FOR CAPS STAFF ONLY

Request Approved

Request Denied

Form Effective Date: November 2018

5 Year Retention Period

UCSB Counseling and Psychological Services Front Desk

Signature:

Date:

FOR CAPS STAFF ONLY

Date Received: ______________

Credited in BARC: Batch No.______________ Initial & Date___________________

Entered in BARC:

Void/Reversed in PNC (Initial & Date):______________________

Staff Signature:__________________________

Date:_________________

Entered in to FW Log (Initial):______

Notified Student (Initial & Date):____________________

Batch No.______________ Initial & Date __________________

Comments:___________________________________________________________________________________________________