Student Wellbeing Assessment Appointment

Student Wellbeing Assessment Appointment Form

Your Details

Please note: we are not an emergency mental health service.  Please do not complete and submit this form if you are seeking support in an emergency.
We are open Monday to Friday, 8.45am – 5pm, except for public holidays and the week between Christmas and New Year.
If you are looking for help in an emergency or feel you need support urgently, please see information on our web pages about emergency and 24 hour support

Please provide the following information to help us respond to your request for an appointment as efficiently as possible:


Please note we will normally only email you at your university email address, so please check this regularly

* Is it OK to leave a message on this number?



* Please indicate at which University site you would like to make an appointment (tick more than one if appropriate):





* Would you be happy to have your initial appointment by phone? (This may mean you do not have to wait as long for an appointment at a particular site.)



What are your preferred days/times for arranging an initial appointment? (We offer appointments typically between 9am and 4pm)











* Please indicate the issue(s) for which you are seeking support (tick more than one if appropriate):













* Are you currently receiving any counselling or mental health support?



Confidentiality and Privacy Statement

The information you provide on this form will usually remain confidential to the Student Wellbeing team.  Other University staff within Student Support and Wellbeing Services may be made aware you have contacted the Student Wellbeing team, in order to try and provide the best possible support to you.
However, there may be circumstances where we may feel it necessary or be bound by law to share information, with or without your consent or knowledge, and liaise with appropriate University staff and/or persons or organisations external to the University. Such circumstances are rare and usually relate to a serious concern for your own or someone else’s wellbeing.  Where possible and appropriate, we would usually attempt to discuss any such circumstances with you prior to taking any action.
In addition, University IT staff need to help maintain electronic systems used within the Student Wellbeing team, and this may mean that occasionally, when fixing a problem for example, they are able to see names and general details of students for whom we hold records.
Any information you provide to us, or that we wish to record in relation to providing support to you, will be stored electronically and processed in line with Data Protection Law. We need to store and process this information in order to provide a service to you. 

* Please tick to show that you have read, understand and agree to this Statement


Send
For information the University’s Privacy Statement can be found here: Staffordshire University ensures information is stored and handled in accordance with  data protection law. Please read our data protection policies for more details.