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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

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Please enter in MM/DD/YYYY format - for example, September 20, 1990 would be 09/20/1990
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Select a date from the calendar.
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Must be a valid Nipissing University email address (you@community.nipissingu.ca)
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Academic Information


For example, Bachelor of Arts in History or Bachelor of Science in Psychology with Concurrent Education


Mental Wellness Information



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.

Nipissing University
100 College Drive, Box 5002, North Bay, ON, Canada  P1B 8L7
Tel: 705.474.3450 | Fax: 705.474.1947 | TTY: 877.688.5507
nuinfo@nipissingu.ca
Brantford Campus
50 Wellington St.
Brantford, ON, Canada N3T 2L6
Tel: 519.752.1524 | Fax: 519.752.8372

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