To make an appointment with one of the wellbeing team for counselling, mental health and or general support please complete referral form. We will then contact you as soon as possible to book a convenient time.

Please fill in the details below, then click the Submit button.

Required fields marked with a star

Fullname

Email address

Date of birth

Student Number

Nationality

Gender

Contact telephone number

Are you registered with a Sunderland based GP? Yes No

Can we leave a message? Yes No

Are you available for a telephone assessment? Yes No

Academic Details

Faculty -- Select an option -- Health, Sciences amd Wellbeing Eduction and Society Business, Law and Tourism Arts and Creative Industries Engineering and Adv. Manufacturing Computer Science London Campus

Year of Study -- Select an option -- 1st 2nd 3rd 4th Research

Course

Please select a maximum of 3 issues to be addressed Emotional and mental health
Physical health
Academic issues (course, assignment/exam, time management)
Stress feeling anxious or panic attacks
Low mood, motivation issues or insomnia
Financial difficulties
Accommodation difficulties
Family/personal difficulties
Bullying/harassment
Addiction
Sexual health
Bereavement/loss
Welfare and employment
Spirituality
Other

Please share any further information with us to assist in your appointment

Impact on University

Are you missing seminars/lectures? Yes No

Do you consider yourself at risk of failing your course? Yes No

Are you considering leaving or deferring university? Yes No

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Assessment of risk

Are you feeling suicidal at the moment? Yes No

If yes - do you plan to act on these feelings? Yes No

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Referral details

Please state any times when you are available.

Self referral Yes No

How did you learn about the service? Progression Team
Leaflet
Website
GP
SU
Faculty
Student Services
Family or friend
Other