Name: * Preferred Name: Preferred Pronoun: - Select One - He/Him/His She/Her/Hers They/Them/Theirs Other Prefer not to answer Student ID: * Program: * - Select One - Business & Administrative Studies Apprenticeship Trades Pre-Employment Trades Human Service Careers Academic Upgrading Resource Technology University Studies Health Careers Continuing Education & Corporate Training Campus Location - Select One - Slave Lake Main Campus Grouard Campus Athabasca Campus Atikameg Campus Cadotte Lake Campus Chateh Campus Driftpile Campus East Prairie Community Access Point Fort Vermilion Campus Gift Lake Campus Grande Prairie Campus High Level Campus High Prairie Vision Campus High Prairie Health Learning Centre La Crete Community Access Point Marten Lakes Wilderness Campus Smoky River (McLennan) Community Access Point Paddle Prairie Community Access Point Peace River Campus Northern Lakes College Shell Canada Power Engineering and Technology Centre Peavine Campus Peerless/Trout Lake Campus Slave Lake Trades and Technology Centre Valleyview Campus Wabasca Campus Home-Based 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. Leave Blank