Near North District School Board
963 Airport Road
North Bay  Ontario  P1B 8H1
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Referral:
Self Referral (Over the age of 12) ID
Date: 2025-05-09 01:27
Status: Draft
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Hide/ShowSelf-Referral (Over the age of 12):

* This is not a crisis support; you will not be contacted immediately *

* If you are having thoughts of suicide or of hurting yourself, please tell a trusted adult or contact Hands Crisis Line: 1-844-287-9072 or Kids Help Phone: 1-800-668-6868 *

Please tell us how we can help you:
Referral Source:
Hide/ShowPlease Tell Us Who You Are:
First Name:
Last Name:
Preferred Name:
Date of Birth:
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Pronouns:
Gender:
Postal Code:
Hide/ShowSchool:
School Name:
What grade are you in:
Hide/ShowPlease Tell Us How to Contact You:

* Please provide the best way for us to contact you *

Phone (Home/Main):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
 
Phone (Alt):
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
 
Email:
Permission to contact via Email:
Yes
No
 

By sending this form, I allow a member of the NNDSB Mental Health Team to contact me.

All information is protected under Ontario privacy legislation and is kept confidential.
 
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