PCD Appointment Request

Instructions

Thank you for taking the step to connect a student to support. Due to the COVID-19 pandemic, Westchester Community College’s main campus and extension sites are closed. The Personal Counseling Department is providing services remotely and is working hard to make sure each student is receiving the support they need. We will be following up with this student shortly, and will be providing them with appropriate resources and options for support moving forward.

Preferred Name (First and Last) *

Legal name (If Different)

Pronouns

(check all that apply)

He/ Him/ His

She/ Her/ Hers

They/ Them/ Theirs

Other (please specify)

Student ID *

Date of Birth *

WCC Email *

Phone Number *

Can we leave a voicemail at this number? *

Yes

Other Email

Briefly explain reason seeking appointment *

Are you currently connected to or have you previously received services from any of the below WCC programs?

(check all that apply)

Student Support Services

Veterans Services

Disability Services

TRIO, EOP, or Viking Roads

Are you currently enrolled in courses at Westchester Community College? *

(eg; for current semester or registered for upcoming semester)

Yes

Please indicate any of the below services you are interested in *

(check all that apply)

Individual, short-term mental health counseling with a Personal Counselor

Online mental health and wellness workshops

Referral to long-term therapist/mental health provider outside of WCC

Healthy Relationships Group (offered via Zoom)

COPING: Mental Health Support Group (offered via Zoom)

Monthly Men’s Support Group (offered via Zoom)

Monthly Support Group for Womxn of Color (offered via Zoom)

Monthly Grief Support Group (offered via Zoom)

Do you have access to internet and a private location to meet with a Personal Counselor via Zoom for Healthcare? *

Yes

Are you currently living in/located in the state of New York? *

Yes

What is your preferred language to receive Personal Counseling services? *

English

Spanish

Please acknowledge you have read below statements *

I am aware that the Personal Counseling Department is not a crisis response service and will only respond to me during hours of operation.

If I am experiencing a mental health emergency, I will contact 911 or go to my nearest emergency room.

Initials *

Captcha *

reCAPTCHA is required.