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Student ServicesWellbeing Referral Form

Thank you for your referral to Student Services.

The application form asks you for some information about yourself and will help us to process your referral so we can offer you the correct service.

If you have any difficulties filling in this form, please contact us for support. To returnit:

  • Either complete and send as email attachment to
  • Or, hand in to the Student Services reception.

We will do our best to contact you within 24 hours on a working day to notify you of receipt and approximate wait time.

Your personal details

First names Sur Surname

Your Regnum: Your age on 20/09/2017:

Your gender: Male Female Other
Your course details


Course title Academic School

Undergraduate Year of study: Year 1 Year 2 Final Year

Postgraduate PGCE Other (please state)
Your contact details

Home  Mobile 

Email address:
Name and address of your GP:
Please tick when you ARE available to attend - the more times you give us, the more likely we will be able to match you to an available appointment:
Monday / Tuesday / Wednesday / Thursday / Friday
Morning
Afternoon
Background Information
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at all / Several days / More than half the days / Nearly every day
1. / Little interest or pleasure in doing things / 0 / 1 / 2 / 3
2. / Feeling down, depressed, or hopeless / 0 / 1 / 2 / 3
3. / Trouble falling or staying asleep, or sleeping too much / 0 / 1 / 2 / 3
4. / Feeling tired or having little energy / 0 / 1 / 2 / 3
5. / Poor appetite or overeating / 0 / 1 / 2 / 3
6. / Feeling bad about yourself – or feeling you are a failure or have let yourself or your family down / 0 / 1 / 2 / 3
7. / Trouble concentrating on things, such as reading the newspaper or watching TV / 0 / 1 / 2 / 3
8. / Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual / 0 / 1 / 2 / 3
9. / Feeling you want to hurt yourself in some way – or have hurt yourself recently / 0 / 1 / 2 / 3
10. / Thinking about or feelingthat you would like to end your life / 0 / 1 / 2 / 3
11. / Feeling nervous, anxious, or on edge / 0 / 1 / 2 / 3
12. / Not being able to stop or control worrying / 0 / 1 / 2 / 3
13. / Worrying too much about different things / 0 / 1 / 2 / 3
14. / Trouble relaxing / 0 / 1 / 2 / 3
15. / Being so restless that it is hard to sit still / 0 / 1 / 2 / 3
16. / Becoming easily irritable or annoyed / 0 / 1 / 2 / 3
17. / Feeling afraid as if something awful might happen / 0 / 1 / 2 / 3
18. / Feeling alone and isolated / 0 / 1 / 2 / 3
19. / Being disturbed by unwanted thoughts and feelings / 0 / 1 / 2 / 3
20. / Thinking about leaving my course / University / 0 / 1 / 2 / 3
21. / Feeling I have someone to turn for support when needed / 0 / 1 / 2 / 3
22. / Feeling I have been able to do the things I need to / 0 / 1 / 2 / 3

Have you ever been given a formal diagnosis? Yes No
If yes, please give details: ______

Are you taking any prescribed medication? Yes No
If yes please give details (medication type and dosage): ______
______
Have you had any previous counselling elsewhere? Yes No
Are you currently seeing any other ‘helping professional’? Yes No
(If yes, please tick () any that apply.)
Psychologist / Nurse / Psychiatrist
Consultant/Medical Specialist / Community Psychiatric Nurse / OT / Social Worker / Community Mental Health Team
Dietician / Counsellor - elsewhere / Other (please specify below)
Other ………………………………………………………………………………………………..
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Choose a number from the scale below to show how much you would avoid each situations or objects listed below. Then write the number in the box opposite the situation.
0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8
Would not avoid it / Slightly avoid it / Definitely avoid it / Markedly avoid it / Always Avoid it

1. / Social situations due to a fear of being embarrassed or making a fool of myself.
2. / Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness). /
3. / Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confirmed spaces, driving or flying).
If you would like to provide extra information about how you are feeling, please write here:
Declaration
I confirm that I would like to refer myself into the Student Wellbeing Services.
Signature……………………………………………… Date………………………………

Student Wellbeing Service

Disclosure / Confidentiality Agreement Form

  1. The purpose of this form is to:
  1. Ensure that members of staff who need to know about a student’s wellbeing, in order to offer appropriate support, are given the relevant information.
  2. Provide written confirmation from a student about the level of confidentiality he/she wishes to be assigned to the disclosure of their personal circumstances, health and academic, in accordance with the Data Protection Act 1998.

I agree that information relating to my personal circumstances can be made available to relevant St. Mary’s University staff or other related professionals who need to know only for the purpose of making appropriate provision for my support.

I understand that if the Student Wellbeing Services believes I am a danger to myself or others liaison with my GP and/or other relevant parties may become necessary without my consent.

Along with Student Wellbeing Service, we might need to share your information with other departments or external agencies.

Please tick preferred method of Communication

Email  / Text  / Telephone 

Please tick the boxes below for which you wish to include in sharing information:

Internal: / External
Parent/Guardian /  / Dyslexia Diagnostic Assessor / 
Academic departments /  / DSA Needs Assessor/Access Centre / 
Registry (e.g. exam arrangements) /  / Student Finance / 
Accommodation Office /  / Medical Professionals / 
Funding Service /  / Social Services / 
Sport St. Mary’s (e.g. gym or sports’ clubs) /  / Care Agencies / 
Library (Personal Induction) /  / Placements / 
Centre for Work-Based Learning (help with placements) / 
Security/Health & Safety / 

Student Name(printed):……………………………………Regnum:……………………….

Student Services Referral Form

To help us understand how we can best support you we have developed this questionnaire to gather important information regarding your situation concerning Accommodation, Funding, Disability and Mental Health.

Are any of the following areas below causing you to stress or worry?

Health Course Feeling homesick Not fitting in

Finances Accommodation Family/Friends Sexuality

Accommodation

Are you experiencing any accommodation related difficulties? Yes No

If yes, would you like to be referred to the

Accommodation Service for advice? Yes No

Funding

Are you struggling to pay for basic expenses e.g. rent, food & travel?

If yes, would you like to be referred to the Funding Service for

advice?

Disability

Do you have a recognised disability (this includes learning difficulties such as dyslexia and ADHD or a mental health condition such as anxiety and depression?

Yes No

If yes, please give information below:

______

If you do not have a diagnosed disability, do you think you may have potential traits of any of the following conditions?

Dyslexia Dyspraxia ADHD/ADD

Autism Mental Health Condition

STRICTLY CONFIDENTIAL

EQUAL OPPORTUNITIES MONITORING FORM

St Mary’s University is committed to a policy of equal opportunities. To help us monitor our effectiveness will you please provide the details below by ticking the appropriate boxes. This information will form a confidential statistical record.

Gender

I am: Male Female Other

Age

Under 2121-30 31-45 46-65 Over 65

Disability

Do you consider yourself to have a disability? Yes No

If yes, please give details about your disability below:

………………………………………………………………………………………………………………………………

Nationality

Please specify: ……………………………………………………………………………………………………………

Ethnic Origin & Cultural Background

Asian or Asian British – BangladeshiMixed – White & Black African

Asian or Asian British – IndianMixed – White & Asian

Asian or Asian British – PakistaniMixed – White & Black Caribbean

Other Asian BackgroundOther Mixed Background

Black or Black British – AfricanWhite - British

Black or Black British – CaribbeanWhite - Irish

Other Black BackgroundOther White Background

Chinese – British Other Ethnic Background (please specify)

Chinese …………………………………………………………

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