PLEASE NOTE: Questions in this registration will refer to the ORIENTATION PACKET that is located on the NSU webpage https://www.nova.edu/studentcounseling/forms.html under the FORMS tab.

First Name: Middle Initial: Last: Student Id #: DOB:

Preferred Address for Correspondence: Address Line 2:

City: State: Zip: Gender: Select... Female Transgender (FTM) Genderqueer Male Transgender (MTF) Chose not to disclose Other Unknown Sexual Orientation: Select... Straight or Heterosexual Bisexual Chose not to disclose Lesbian, gay or homosexual Other Unknown

Email: **By entering your email address, you give permission to receive email communication from Henderson Student Counseling Services.

Local Address if Different From Above: Address Line 2:

City: State: Zip: Are you a Veteran?: Select... Yes No Are you a Smoker?: Select... Yes No

Cell: Preferred? Select... Yes No Home: Preferred? Select... Yes No Primary Language Spoken In the Home:

Do You Have Insurance?: Select... Yes No Company Name if Yes: Member #: Group #:

Student Status: Select... Undergrad Grad Which Program Are You In?:

Race: Select... Asian Black Hispanic Black/African American Multi-Racial White Hispanic White/Caucasian Other If Other:

How Did You Hear About Us?: Select... Email Orientation Word of Mouth Website Prof/Faculty Flyer Other Agency Counselor in Residence Grades First

What would you like to focus on in counseling?:

If you are experiencing thoughts of hurting yourself or others please call 911 immediately.

EMERGENCY CONTACT: By filling in the information below, I give permission to speak to my Emergency Contact if necessary

Name: Relationship:

Address: Phone:

Medical and Counseling Information

Are You Being Treated For Any Medical Conditions?: Select... Yes No

If Yes, Describe:

Are You Taking Medications?: Select... Yes No

If Yes, Name and Dosage:

Reason for Medications:

Name Of Doctor: Telephone Number:

Have You Ever Been In Counseling Before?: Select... Yes No

If Yes, Dates: With Whom:

Have You Ever Been Hospitalized?: Select... Yes No

If Yes, for What?:

YesNo Please select YES if you give your permission to allow HSCS to speak with NSU officials should there be a perceived incidence of threat due to the growing occurrence of violence on college campuses nationwide.

YesNo I have reviewed the information in the Orientation Packet, located on the website, and have received my Notice of Privacy Practices.

YesNo If I choose to participate in telehealth services, I agree to download and review the Student Counseling TeleHealth Services Informed Consent to be reviewed by my counselor in session.

YesNo Please select YES if you give permission to allow the Henderson Behavioral Health psychiatrist to access your medication history data for use when prescribing medication, only if receiving services with the psychiatrist.

Telehealth Consent Form

Campus Information

Campus:

Select... Davie Ft. Myers Jacksonville Miami Orlando Palm Beach San Juan Tampa

Please Upload 3 Files, Picture of your Government Issued ID, Your Class Schedule, and Student ID

Files must be one of these file types: .bmp|.gif|.png|.jpg|.jpeg|.pdf and must be less than 10 MB

1st CHOOSE the file you wish to upload and 2ND you must click UPLOAD FILE to attach document