Counselling Services Registration Form

North Bay Campus

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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

Pronouns
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

500 Internal Server Error

Internal Server Error

The server encountered an internal error and was unable to complete your request. Either the server is overloaded or there is an error in the application.