Student Wellbeing Referral Form

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

Full name

Student Number

Date of birth

Nationality

Email address

Contact Address

Contact telephone number

(The initial assessment will be by phone)

Are you registered with a Sunderland based GP?

Yes No

Please provide the practice name

I identify my gender as

Academic Details

Faculty

Year of Study

Course

Campus

Please indicate times when you are available for an appointment (We may be able to allocate appointments at short notice).

The more flexible you are with times and days, the sooner you are likely to be contacted.

We are based at the City Campus, 1st floor Edinburgh Building. In addition we also offer sessions at St Peters Campus (Mon-Fri).

Please state any times when you are available.

Please share your reasons for accessing the service.

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

Assessment of risk

Are you feeling suicidal at the moment?

Yes No

If yes - do you plan to act on these feelings?

Yes No

If "yes" then please ensure you contact the local Crisis Team 0303 123 1145. They are open 24/7 and are there for people over the age of 16 experiencing a mental health crisis.

Other sources of support:

The Samaritans 08457 90 90 90 / jo@samaritans.org

SANEline 0845 767 8000, open 1pm-11pm every day www.sane.org.uk

24-hour National Domestic Violence Freephone Helpline 0808 2000 247

Your GP

Your Accident & Emergency Department (24 hours)

Self referral

Yes No

How did you learn about the service?

Progression Team
Leaflet
Website
GP
SU
Faculty
Student Services
Family or friend
Other

Please state below

Please state

Places I've been

Saved pages

Recently visited

Academic Details

Impact on University

Assessment of risk

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