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 have never been to CAPS or it has been longer than 3 months since your last appointment, please use the New Client link to make an Access Appointment. First name: * Last name: * Student ID: * What are your pronouns: Date of Birth: * Class Year: * Cell phone number: * Swarthmore Email Address: * Emergency Contact (Must be over 21 years old) Name * Phone Number * Your relationship to Emergency Contact (Sibling, parent, friend, other) * CAPS Information Provide any information regarding identities you would like your therapist to know: I am seeking counseling because: * I am having current thoughts of suicide (if you are feeling unsafe, please call CAPS On-Call (610-328-7768) I have a current plan to harm someone else I have been hospitalized for mental health reasons in the last month I have recently been physically or sexually assaulted I am hearing voices or seeing things that others do not Other reasons Other reasons such as: Do you prefer to return to the same counselor you saw during the Fall semester? * Yes, I would prefer to work with the same clinician if our schedules permit it. No, I would prefer to try working with someone new if schedules permit it. I do not have a preference. I would prefer to meet with a CAPS Care Manager to receive help finding an off-campus therapist or other mental health service. If you would prefer to return to the same CAPS counselor, please share the name of the provider. Are you open to in-person appointments? * Yes No Are you open to virtual appointments using the HIPAA-compliant Zoom platform? * Yes No Do you have a preference between in-person or virtual appointments? * I prefer In-person I prefer Zoom No preference Are you interested in learning more about group therapy at CAPS? * Yes No Schedule AvailabilityWhen are you are available to attend counseling? Please select at least 4 options. More times will make it easier to schedule. Monday 9am-10am 11am-12pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm Tuesday 9am-10am 10am-11am 11am-12pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm Wednesday 9am-10am 10am-11am 11am-12pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm Thursday 9am-10am 10am-11am 11am-12pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm Friday 9am-10am 10am-11am 11am-12pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm Leave this field blank
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 have never been to CAPS or it has been longer than 3 months since your last appointment, please use the New Client link to make an Access Appointment. First name: * Last name: * Student ID: * What are your pronouns: Date of Birth: * Class Year: * Cell phone number: * Swarthmore Email Address: * Emergency Contact (Must be over 21 years old) Name * Phone Number * Your relationship to Emergency Contact (Sibling, parent, friend, other) * CAPS Information Provide any information regarding identities you would like your therapist to know: I am seeking counseling because: * I am having current thoughts of suicide (if you are feeling unsafe, please call CAPS On-Call (610-328-7768) I have a current plan to harm someone else I have been hospitalized for mental health reasons in the last month I have recently been physically or sexually assaulted I am hearing voices or seeing things that others do not Other reasons Other reasons such as: Do you prefer to return to the same counselor you saw during the Fall semester? * Yes, I would prefer to work with the same clinician if our schedules permit it. No, I would prefer to try working with someone new if schedules permit it. I do not have a preference. I would prefer to meet with a CAPS Care Manager to receive help finding an off-campus therapist or other mental health service. If you would prefer to return to the same CAPS counselor, please share the name of the provider. Are you open to in-person appointments? * Yes No Are you open to virtual appointments using the HIPAA-compliant Zoom platform? * Yes No Do you have a preference between in-person or virtual appointments? * I prefer In-person I prefer Zoom No preference Are you interested in learning more about group therapy at CAPS? * Yes No Schedule AvailabilityWhen are you are available to attend counseling? Please select at least 4 options. More times will make it easier to schedule. Monday 9am-10am 11am-12pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm Tuesday 9am-10am 10am-11am 11am-12pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm Wednesday 9am-10am 10am-11am 11am-12pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm Thursday 9am-10am 10am-11am 11am-12pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm Friday 9am-10am 10am-11am 11am-12pm 1pm-2pm 2pm-3pm 3pm-4pm 4pm-5pm Leave this field blank
