Community Mental Health Services : Contact Form

Contact Form

Note for West Chester University Students seeking therapy services: Please contact West Chester University Counseling and Psychological Services Center at 610-436-2301. You may complete this form if you are looking for assessment services. All other community members, WCU staff, and faculty, please complete this form for either service.

Contact Information

Please make sure you have filled in all required fields with valid information.

How did you hear about us?

How did you hear about us - Other:

First Name:

Last Name:

Are you seeking services for yourself?

Yes No

Please provide the following information for the individual you are seeking services for:

Your relationship to the individual:

First Name:

Last Name:

Are you over 18?

Yes No

Phone Number:

- Phone (next 3 digits): - Phone (next 4 digits):

Email:

Address:

City:

State:

Zip Code:

Request Information

Please make sure you have filled in all required fields with valid information.

Are you inquiring about:

Therapy Services
Assessment Services
BRAVE-PS for public speaking
Healing from Racial Trauma Group

Please provide a brief explanation for your request:

What is the best day/time to reach you?

(optional)