subject_line

Assistance Request Form

I am... *

requesting assistance for myself.

referring a student.

reporting drug or alcohol abuse.

Other Other

Name *

Z ID *

Phone number *

Email address *

Student's name *

zID (if known)

Student's email address

Student's phone number

Please explain how we can offer support. *

Your NIU affiliation *

Student

Faculty/staff

Family member/friend

Other Other

Your name *

Your email address *

Your phone number