CCAC Mental Health Services-- Self Referral Form

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CCAC Guns Down Level Up and AHN's The Chill Project will be offering mental health services to interested HBC and Allegheny Campus students, based upon availability. Please fill out the form below to request information and/or refer yourself for the opportunity engage in services, as spots are available :)

Full Government Name? *

Preferred name, if different from above :)

At which campus are you currently enrolled in courses? *

Allegheny Campus

Homewood-Brushton Center

South Campus

North Campus

Boyce Campus

Braddock Hills Center

West Hills Center

Online

Other:

Who referred you to these services? *

Self

Counselor

Professor

Administration

Other:

Preferred Contact Number *

How did you hear about these services? *

Digital Signage

Counselor

Professor

Administration

Other:

OPTIONAL-- If you are would like to share any details or additional information about your inquiry/referral, please feel free to do so below.

I consent to being contacted by the AHN/CCAC Mental Health Therapist about my referral request *

Yes

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