Fillable STUDENT COUNSELLING SERVICES (SCS) REGISTRATION FORM Surname First (Nipissing University)

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STUDENT COUNSELLING SERVICES (SCS) REGISTRATION FORM Surname First (Nipissing University)

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The STUDENT COUNSELLING SERVICES (SCS) REGISTRATION FORM Surname First (Nipissing University) form is 2 pages long and contains:

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Country of origin: CANADA
File type: PDF

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1
Date:
The purpose of this confidential form is to gather some preliminary information for Counselling staff. This information is
used to provide you the best supports possible and improve our services. Once you complete this form please
download a copy and then email to counselling@nipissingu.ca. Please note you can anticipate a response within 24
hours after submitting your registration form. (Hours: Monday – Friday 8:30 AM – 4:30 PM, excluding holidays)
Surname First Name Student ID
Preferred name Date of Birth (Month/Day/Year)
Current Address or Residence & Room Number Phone □ Able to leave a voicemail
City Postal Code
E-mail
@my.nipissingu.ca Gender
Pronoun(s): □ He/Him □ Her/She □ They/Them □Other
Please check all that apply:
□ International Student
□ Registered with Student Accessibility Services
□ Indigenous: First Nation (Status and Non-Status)
□ Student Athlete
□ Residence Life Team (i.e. Don, CA, etc.)
□ Gen 1 (neither parent attended post-secondary education)
□ Mature/Transfer Student
How did you hear about counselling
services? (Please check all that apply)
□ Self □ Family Member □ Student □ Promotional Materials
□ Health Centre □ Nipissing Faculty / Staff □
Other: ___________________
Select which applies to you:
□ First time accessing Student Counselling Services
□ Returning Student: have accessed Student Counselling Services in prior years
□ Returning Student: have accessed Student Counselling Services this academic year
Do you have a family Doctor?
□ Yes □ No
If yes, please provide Name & City:
Program Name: (e.g. Bachelor of Arts- History) ________________________________________
STUDENT COUNSELLING SERVICES (SCS) REGISTRATION FORM
2
Year of Study: Undergraduate student: □ 1
st
□ 2
nd
□ 3
rd
□ 4
th
□ Graduate Program year: ______ □ PhD Program year: ______
□ 1st year B.Ed Program or 5
th
year Concurrent □ 2nd year B.Ed □ Non-Degree studies
Are your university studies being affected by your concern? □ Yes □ No
If yes, please check all that apply:
□ Ability to concentrate
□ Stress management
□ Study skills
□ Ability to attend class
□ Ability to complete assignments
□ Adjusting to university
□ Work / life / study balance
□ Considering withdrawing
□ Overall academic performance (grades)
Have you ever received counselling in the past, outside of SCS? □ Yes □ No
If you have received counselling services in the past, either with SCS or aside from SCS, briefly
share with us what you have found helpful and unhelpful?
What is going well in your life?
What would you like to focus on in your appointment when you meet with a counsellor?
Same day appointments can be available to address what is important today. Please provide a few
dates and times that you are available for an appointment:
If you feel your current situation requires
an appointment as soon as possible, please indicate here:
If you are in crisis and would like to speak with someone now, telephone support is available 24/7 by
calling the Nipissing Crisis Intervention Line 1-800-352-1141 or the Good2Talk Helpline 1-866-925-5454.
If you feel you might hurt yourself or somebody else, call 911 or go directly to the Emergency Room at
the hospital.
Emergency Contact Name:
Phone:
Relationship to Student:
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
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STUDENT COUNSELLING SERVICES (SCS) REGISTRATION FORM Surname First (Nipissing University)

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Completed 5 February 2021

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