Self-Referral Form: Northern Lakes College

Self-Referral Form

Name: *

Preferred Name:

Preferred Pronoun:

Student ID: *

Program: *

Campus Location

Contact number:

Please check one: *

I am over the age of 18 and actively attending a credit course or program with Northern Lakes College.

I am under the age of 18 and actively attending a credit course or program with Northern Lakes College.

I am not a student.

What is the primary reason that you are looking to connect a member of our Team? *

BOOK A WELLNESS CHECK UP

I am struggling with my learning

I would like support with a personal, career, or well-being issue

I would like support planning my education and career

I would like help with navigating issues, processes, appeals, etc.

I have a diagnosis and would like to know what supports I can access

I’d rather not say on this form

Other (please describe below):

(Fill in Box)

Please check off each box indicating that you have read and agree to the statement. *

I agree to have a member of the Student Services Team contact me to make an appointment.

I understand that when I meet with the team member, they will go over what type of services they offer, their professional credentials, consent and confidentiality. They will also give me an opportunity to ask any questions that I have.

I understand that I have the right to withdraw my request at any time, for any reason.

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