NSU Student Counseling Services Request

NSU Student Counseling Services Request

If you are currently enrolled at NSU, please fill out the form to request services.
Are you experiencing thoughts of harming yourself or someone else?

If Yes, please call 911 immediately, this is not an interactive 24 hour monitored communication system
Name

First NameLast Name
Date of Birth

MonthDayYear
Date of Birth
Gender
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Method of Contact
What is your preferred method of communication for appointment reminders and client portal sign up?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Campus
Please select your currently enrolled campus
Major
Please tell us if you are a graduate student or an undergraduate student.
Please answer the below questions to assist us in connecting you to the most appropriate provider and learn a little more about what you are currently experiencing.
Are you experiencing thoughts of harming yourself or someone else?
Please call 911 immediately, this is not an interactive 24 hour monitored communication system.
What would be your primary area of focus on in counseling?
Are you experiencing psychosis/hallucinations?
Other
Are you experiencing depression or anxiety?
How would you rate the severity of your current symptoms from. 1-5 (5 being severe)?
Are you coming in to address an experience involving a recent assault or harassment situation?
Is your preferred language for services a language other than English?
What language?
If that language is not available, would you be willing to receive services in English?
Race
Ethnicity
Should be Empty: