Counselling Services Registration Form

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

First Name

Last Name

Preferred Name

Student Number

Date of Birth

Today's Date

Local Address or Residence and Room Number

Phone Number

City

Postal Code

Nipissing Email

Must be a valid Nipissing University email address (you@community.nipissingu.ca)

Gender

Pronouns

He/Him

She/Her

They/Them

Other

Do we have your permission you leave a message at the phone number(s) you specified?

Yes, you have my permission to leave a message at the phone number(s) I specified

I cannot attend the North Bay Campus for in-person services

Check this box if you cannot attend the North Bay Campus for in-person services.

Please select all that apply

International student

Registered with Student Accessibility Services

Student athlete

Indigenous: First Nation (Status or Non-Status), Metis, Inuit, or Other

How did you hear about Counselling Services?

Self

Family member

Nipissing University faculty/staff

Student

Health centre

Promotional materials

Other

Academic Information

Mental Wellness Information

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

Yes

No

Have you ever received other counselling services in the past?

Yes

No

What are you hoping to begin to change about your life during this time in counselling?

For scheduling purposes, please provide a few days and times of week that you are usually available to attend sessions (All appointments are Monday to Friday. The first appointment starts at 9am the last appointment starts at 3pm):

Consent

If you would like to speak with someone now, 24-hour telephone support is available by calling the Nipissing Crisis Intervention Line 1-800-352-1141 or the Good2Talk Helpline 1-866-925-5454. If you feel like you might hurt yourself or somebody else, call 911 or go directly to the Emergency Room at the hospital.

In order to complete this form, you must agree to the following

I understand that this information will be provided to Student Counselling Services at Nipissing University and that if I haven’t already booked an appointment, staff will be contacting me to arrange my first appointment