Northwestern University
Counseling & Psychological Services
Preliminary Information Form
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Please enter your personal information below.
First Name:
*
Middle Name:
Last Name:
*
Preferred Name:
Pronouns:
Date of birth
*
Student ID from NU Wildcard:
*
Home Phone:
Is it OK to phone you at this number?
Yes
No
Cell Phone:
*
Is it OK to phone you at this number?
*
Yes
No
Email:
*
Is it OK to email you?
Please note that e-mail is only used for scheduling/canceling appointments and for appointment reminders.
*
Yes
No
Local Address
*
OK to contact at Local address?
Yes
No
Permanent Address
*
OK to contact at Permanent address?
Yes
No
Name, address, and phone number of an emergency contact person. Please also indicate how this person is connected to you (e.g., parent):
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Yes.
for,
No.