Counselling Services Registration Form

North Bay Campus

Required fields are marked with an asterisk (*)

Student Counselling Services Registration

The purpose of this confidential form is to gather some preliminary information for Counselling staff in order to schedule you an intake appointment. This information is used to provide you the best supports possible and improve our services. Counselling staff will contact you to book an intake appointment if one has not already been scheduled. Please answer the following questions as best you can.

Demographic Information

Do we have your permission you leave a message at the phone number(s) you specified?
I cannot attend the North Bay Campus for in-person services
Please select all that apply
How did you hear about Counselling Services?

Academic Information

For example, Bachelor of Arts in History or Bachelor of Science in Psychology with Concurrent Education
One or both of my parents went to University/College
I transferred to Nipissing from another college or university
My current concerns are affecting my academics
How are your university studies being affected by your concerns? (select all that apply)

Mental Wellness Information

Have you received counselling services from Nipissing University in the past?
Have you ever received other counselling services in the past?

Protection of Privacy

The personal information on this form is collected under the authority of the Nipissing University Act, 1992. It is related directly to and needed by the University to provide Student Counselling Services to students in the course of their studies while at Nipissing University. If you have any questions or concerns about the collection, use and disclosure of this information please contact Student Counselling Services at Nipissing University, 100 College Drive, North Bay ON, P1B 8L7, (705) 474-3450 ext. 4493.