CAPS: Request to schedule an appointment

If this is an emergency:

If 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: *

Address (Your current location)

Street *

City *

State *

Other

Country *

Please provide any information regarding salient identities you might like your therapist to know:

Have you been to CAPS before?

Yes

If YES, would you like to see the same therapist? (Note that CAPS is not always able to accommodate preferences)

Yes

Who was your therapist?

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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