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*

MaleFemalePrefer not to answer
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
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.*

GradUndergrad
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?*

YesNo
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?*

YesNo
Other
Are you experiencing depression or anxiety?*

YesNo
How would you rate the severity of your current symptoms from. 1-5 (5 being severe)?*

12345 (severe)
Are you coming in to address an experience involving a recent assault or harassment situation?*

YesNo
Is your preferred language for services a language other than English?*

YesNo
What language?
If that language is not available, would you be willing to receive services in English?

YesNo
Race*
Ethnicity*
Should be Empty: