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 used for scheduling/canceling appointments only!
*
Yes
No
Local Address
*
OK to contact at Local address?
Yes
No
Permanent Address
*
OK to contact at Permanent address?
Yes
No
In case of Emergency, whom should we contact? Name, Address, Phone Number, Relationship
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