CAPS: Request to schedule an appointment

Student ID #: *

First name: *

Last name: *

Class Year: *

Email: *

Cell phone number: *

What are your pronouns:

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

Have you been to CAPS before?

Yes

No

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

Yes

No

If so, who was your therapist?

Type of Service Requested:

Assessment for counseling

Weekly Group psychotherapy

Off campus referral for counseling or psychiatry

The reason I am seeking counseling is: *

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 additional information about your counseling request:

Today's Date:

Year

Month

Day

Animation: