Nagasaki University Counseling Appointment Form

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Welcome to the Nagasaki University Health Center counseling appointment form.

Please be aware that this form is only for requesting an appointment. You should not use this form if you have an emergency or require immediate help. You may also contact the health center by phone on weekdays, 8:45 a.m. - 5:30 p.m., at 095-819-2214 (please note that staff have limited English ability).

To request a counseling appointment, fill in the required fields below (fields marked with an asterisk (*) are required). After you have submitted the form, you will be contacted by the counselor responsible for your school or department. A counselor will generally contact you within 3 business days. If you do not hear from a counselor within that time period, the form may not have been sent correctly. Please resubmit the form, or contact the health center by phone.

If you would like to make an appointment for online counseling, please first read and agree to the terms of service for online counseling (http://www.hc.nagasaki-u.ac.jp/online-note2)

A list of other resources (such as those related to mental health, suicide, domestic violence, and social services) can be found on this Nagasaki Prefecture web site: http://www.pref.nagasaki.jp/bunrui/hukushi-hoken/jisatsuyobotaisaku/jisatsu/soudan-jisatsu/

Note: Most of the resources listed are only available in Japanese. For information on free, telephone- or text-based counseling in English, please visit the TELL web site: https://telljp.com/ or Yorisoi Hotline: https://www.since2011.net/yorisoi/n2/

Name (family name, first name) *

Affiliation with Nagasaki University *

Student

Faculty/staff

Your student/employee ID number *

Your school, department, etc. (Students: enter name of your school/academic department and course or major. Faculty/staff: enter the name of your office/department) *

Faculty/staff only: enter your job title (physician, nurse, faculty member, etc.)

Phone number (e.g., XXX-XXXX-XXXX) *

E-mail address *

Desired counseling format *

In-person (face-to-face)

Online (Be sure to read online counseling terms noted above)

Telephone

Any of the above

Preferred appointment day/time (e.g., “Mondays, 13:00 – 15:00”)　Note: Counseling for students is provided between 9:00 and 17:30 on weekdays. For faculty/staff, appointments outside regular office hours are available.

Your primary concern

General mental health (e.g., depression, anxiety)

Interpersonal relationship (including harassment)

Academic/workplace issue

Issue not related to academics or the workplace

The total score of your mental health questions (*a part of the online questionnaire completed for annual student health checks) was equal to or more than 13 points

Other

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