Mental health self-referral

Mental health self-referral

Please note: Information you provide is voluntary and protected as confidential data. You can also request an appointment by phoning 905.721.3392 or emailing studentlifeline@ontariotechu.ca.

Requests are processed Monday to Friday from 8:30 a.m. to 4:30 p.m.

If you require urgent assistance, use one of the following:

Off-campus:
Call 911
On-campus:
Call Campus Security at 905.721.3211
Help lines:
Crisis Services Canada at 1.833.456.4566
Good2Talk at 1.866.925.5454

Name Name First Last
Email
Student number
Must be 9 digits. Currently Entered: 3 digits.
Phone Phone - ### - ### ####
Preferred method of contact

Preferred method of contact Email Phone
If you selected phone, can we leave a message?

If you selected phone, can we leave a message? Yes No
I am at risk of suicide:

I am at risk of suicide: Yes No
Please select one description below that most closely describes your suicide risk:

Please select one description below that most closely describes your suicide risk: I am at immediate risk of suicide. Please call 911 (off-campus) or Campus Security at 905-721-3211 (on-campus) immediately. Note that Student Mental Health Services is not a 24/7 crisis line. We will respond to requests for support within one to three business days. I have frequent and intense thoughts of suicide and can no longer cope. I plan to act on my thoughts within the next few days. Please call 911 (off-campus) or Campus Security at 905-721-3211 (on-campus) if you feel you will act on your thoughts of suicide. Note that Student Mental Health Services is not a 24/7 crisis line. We will respond to requests for support within one to three business days. I have frequent thoughts of suicide and I am having difficult coping. I have thought about how I would act on my thoughts. I have had some thoughts of suicide. I have occasional thoughts about how or when I might take my own life. I have had passing thoughts of suicide and I do not plan on acting on these thoughts.
Reason for appointment

As you check the boxes below, different resources will appear. Once you submit this form, you will receive an email copy of the selected resources.
You will still have an opportunity to request an appointment with a counselor below.
Academic stressors Accessibility challenges Anxiety or worry Eating and/or body image concerns Depression or low mood Employment or career stressors Experienced discrimination, harassment, violence, or exclusion Feeling isolated or disconnected Financial stressors Sexual violence Other Other
Academic stressors

If you need support with math, physics, English or writing, want a peer tutor or need support with study skills, support is available through the Student Learning Centre:
https://studentlife.ontariotechu.ca/services/academic-support/index.php

If you have questions about your academic standing, progress, course selection or goals, you can connect with your academic advisor:
https://academicadvising.ontariotechu.ca/
Accessibility challenges

If you have a physical or mental disability, or need learning accommodations, here is the link for Student Accessibility Services:
https://studentlife.ontariotechu.ca/services/accessibility/index.php
Anxiety or worry

Information and tools from Anxiety Canada:
https://www.anxietycanada.com/

Free skill-building program to help you manage anxiety, stress, worry, low mood or depression:
https://bouncebackontario.ca/
Eating and/or body image concerns

If you're experiencing distress related to food, eating and/or body image, learn more about the resources to help, below:

NEDIC - Eating Disorders and Treatment

Body Brave
Depression or low mood

If you are experiencing low mood or depression, get more information here:
https://depressionhurts.ca/en/

Free skill-building program to help you manage low mood, depression, stress, worry and anxiety:
https://bouncebackontario.ca/
Employment or career stressors

If you would like to receive support for your internship or co-op, attend a career readiness workshop, receive support for job applications and interviews or sit down with a career counsellor:
https://studentlife.ontariotechu.ca/services/career-readiness/index.php
Experienced discrimination, harassment, violence, or exclusion

If you have been the victim of discrimination, harassment, violence or exclusion, you can connect with an Equity Advisor:
https://studentlife.ontariotechu.ca/services/equity-and-inclusion/index.php
Feeling isolated or disconnected

Connect with other Ontario Tech students with similar interests or backgrounds:
https://studentlife.ontariotechu.ca/services/community/index.php
https://otsu.ca/club
Financial stressors

Learn how to apply for financial aid, awards, bursaries on campus work and more:
https://safa.ontariotechu.ca/index.php
Sexual violence

If you have experienced sexual violence, there are many resources to support you:
https://studentlife.ontariotechu.ca/sexualviolence/getsupport.php#tab1-2
Appointment request confirmation

Appointment request confirmation I would like to book a mental health intake appointment. I would like to book an intake appointment with Michelle Pitman, Disordered Eating and Body Image Counsellor. I do not need a mental health appointment at this time.
Mental health peer mentors

Mental health peer mentors I would like to book an appointment with a mental health peer mentor.
Would you prefer a virtual or in-person appointment?

Would you prefer a virtual or in-person appointment? Virtual In-person
Have you had an appointment with us before?

Have you had an appointment with us before? Yes No
Preferred method for session

Preferred method for session Secure video appointment Telephone appointment
Personal information on this form is collected under the authority of the University of Ontario Institute of Technology act (2002), and will be used to the provision of counselling/psychotherapy at Ontario Tech. Questions about this collection should be directed to the Assistant Vice-President, Student Life, Ontario Tech University, 2000 Simcoe Street North, Oshawa ON L1G 0C5, 905.721.8668 ext. 2327