CAPS Appointment Request

In a mental health emergency do not complete this form. Call:

CAPS On-Call at 610-328-7768 or Public Safety at 610-328-8333
The National Suicide Prevention Hotline: 800-273-8255
988 - National Suicide and Crisis Lifeline
911

If you already completed an Access appointment with CAPS during the Fall 2022 semester and you’d like to schedule an appointment at CAPS for a non-emergency please complete the following form:

First name: *

Last name: *

What are your pronouns:

Date of Birth: *

Class Year: *

Cell phone number: *

Email: *

Current Address (if different than address reported to CAPS during Fall 2022)

Street *

City *

State *

Other

Country *

Home Address (if different than address reported to CAPS during Fall 2022)

Street (home address) *

City (home address) *

State (home address) *

Other (Home Address)

Country (home address) *

Emergency Contact (Must be over 21 years old)

Name *

Phone Number *

Your relationship to Emergency Contact (Sibling, parent, friend, other) *

Leave this field blank

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CAPS Appointment Request

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