Email: / Mobile: / Student No.
Postal address:(we will not send any letters to this address without your consent)
Programme of Study: / Duration of Course:
From: / To:
Level of study / ☐Undergraduate / ☐Masters / ☐ PhD
☐General
Course / ☐ Summer
School / ☐ Other
Fee Status / ☐Home / ☐ EU / ☐International
Have you seen a Counsellor or a Mental Health Adviser at LSE before? ☐Yes ☐No
If yes, please give details of who you saw and when this was?
Are you currently seeing a counsellor or other mental health professional? ☐Yes ☐No
Are you registered with a GP? ☐Yes ☐No
Please give your GP Name and Address
Current Medications:
Please read each statement and tick a box to indicate how often you have felt that way over the last week
I have felt tense, nervous or anxious / ☐ / ☐ / ☐ / ☐ / ☐ /
I have felt I have someone to turn to for support when needed / ☐ / ☐ / ☐ / ☐ / ☐ /
I have felt unable to concentrate on my studies / ☐ / ☐ / ☐ / ☐ / ☐ /
I have had thoughts of hurting myself’ / ☐ / ☐ / ☐ / ☐ / ☐ /
Talking to people has felt too much for me / ☐ / ☐ / ☐ / ☐ / ☐ /
I have had difficulty getting to sleep or staying asleep / ☐ / ☐ / ☐ / ☐ / ☐ /
I made plans to end my life / ☐ / ☐ / ☐ / ☐ / ☐ /
I have been over-eating or under-eating / ☐ / ☐ / ☐ / ☐ / ☐ /
I have used drugs or alcohol to cope with my difficulties / ☐ / ☐ / ☐ / ☐ / ☐ /
Please tell us about the difficulties you are having and what kind of help you are seeking?
(Your form will be returned if you do not complete this section)
Sexual Orientation / Gender
Bisexual / ☐ / Female / ☐
Gay Man / ☐ / Male / ☐
Gay Woman/ Lesbian / ☐ / Trans / ☐
Heterosexual / ☐ / Other☐ (please specify)
Other ☐ (please specify) / Prefer not to say / ☐
Prefer not to say / ☐
Ethnic Origin (This information is only used for statistical purposes)
☐Asian or Asian British
-Indian / ☐Black or Black British –
Caribbean / ☐Mixed – White &
Asian
☐Asian or Asian British
-Pakistani / ☐Black or Black British –
African / ☐Irish Traveller
☐ Asian or Asian British –
-Bangladeshi / ☐Other Black background / ☐White
☐ Other Asian background / ☐Mixed – White & Black
Caribbean / ☐Other Mixed
background
☐ Chinese / ☐Mixed – White & Black
African / ☐Other Ethnic
background
☐Prefer Not to Say / Other comment:
Please ensure that you read the confidentiality and data protection statement below before your appointment, (full policy available from Reception, and on our website)
☐I have read and consent to the statement / ☐I require further information
Signed: / Date:
Confidentiality and Data Protection (Full details on our website)
The Counselling Service is confidential and we will not discuss anything about you outside of the Counselling and Well Being Service without your explicit agreement, except in exceptional circumstances. For example, we would have a duty to inform your GP if we were concerned that there was a serious risk of harm to yourself or others.
Confidentiality is a most important part of this service, and the service subscribes to the ethical framework of the BACP (British Association for Counselling & Psychotherapy). To read the service confidentiality policy click here (PDF); this provides detailed information on confidentiality and data protection procedures.
The service stores data in accordance with the Data Protection Act. Counsellors keep their own records of their work, and these notes are held securely and confidentially for 6 years, after which they are destroyed. These records do not form part of any other record system within the university. The service also stores basic information about each student on a secure and confidential database, which is also kept separate to any other student record system. This information is used to compile aggregate data and monitor the service as a whole. No information that can be traced back to individuals will be released by the counselling service.