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
@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) ________________________________________
Year of Study: Undergraduate student: 1
Graduate Program year: ______ PhD Program year: ______
1st year B.Ed Program or 5
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:
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