Counselling Services Registration Form

North Bay Campus

Required fields are marked with an asterisk (*)

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.
Student Counselling Services (SCS) Registration Form
Your Information
Please check all that apply
How did you hear about Counselling Services? (Please check all that apply)
Select which applies to you
Do you have a family Doctor?
Academic Information
Year of Study
Undergraduate student
I am a mature student and/or I have transferred to Nipissing University from another college or university
Are your university studies being affected by your concern?
Please check all that apply
Have you ever received counselling in the past, outside of SCS?

For scheduling purposes, please provide a few days and times that you are available in the next two weeks to attend an appointment (First appointment starts at 9am, and the last appointment starts at 3pm, Monday to Friday):

If you 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 like you might hurt yourself or somebody else, call 911 or go directly to the Emergency Room at the hospital.

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.