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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

Yes No
Yes No
Yes No

Academic Details

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
Sexual health
Welfare and employment

Impact on University

Yes No
Yes No
Yes No

Assessment of risk

Yes No
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 /

SANEline 0845 767 8000, open 1pm-11pm every day

24-hour National Domestic Violence Freephone Helpline 0808 2000 247

Your GP

Your Accident & Emergency Department (24 hours)

Referral details

Yes No
Progression Team
Student Services
Family or friend

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