CAPS: Request to schedule an appointment :: Counseling and Psychological Services

Student ID #: *

First name: *

Last name: *

Class Year: *

Email: *

Cell phone number: *

What are your pronouns?

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

Have you previously been a CAPS client?

Yes

When?

Type of Service Requested:

One time psychological consultation

Scheduled ongoing individual counseling

Weekly Group psychotherapy

Psychiatric Referral

Do any of the following apply to you? *

I have recently been physically or sexually assaulted

I have a current plan to attempt suicide

I have recently taken steps to end my life

I have a current plan to harm someone else

I am hearing voices or seeing things that others do not

None of the above

Provide any other information you would like us to know in relation to your current concern:

Today's Date:

Month

Day

Year

Leave this field blank

Swarthmore College