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

First name *

Last name *

Year *

Email *

Cell phone number *

What are your pronouns

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

Were you a CAPS client last semester?

Yes

No

There are a limited # of Groups openings. Are you interested in a screening appointment for a group?

Yes

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

Check any of the following that apply to you:

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 have recently been physically or sexually assaulted

I am hearing voices or seeing things that others do not

Date of submission

Month

Day

Year

Swarthmore College