Counselling and Mental Health Self-Referral Form
Basic information
Name
*
First Name
Last Name
Birthdate
*
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Day
-
Month
Year
Date
Student ID
*
Nationality
*
Contact Telephone Number
*
Email (Please use BUE email)
*
example@example.com
Emergency contact - Please note that if you don't provide a valid emergency contact you will not be able to proceed with the booking
*
Name
Relationship to student
Emergency contact telephone number
*
Living Status
*
With parents
BUE Residence (Dorms)
Other dorms/residence
Alone or with roommates
Other
Course details
Faculty & Programme
*
Year of study:
*
Please Select
Preparatory Year
Year 1
Year 2
Year 3
Year 4
Year 5
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Reason for referral
Please tell us why you’d like to see a counsellor (tick all that apply)
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Depressed Mood
Anxiety
Loss of someone/grief
Exam/ Study Stress
Anger
Sleep difficulties (example: difficulty falling asleep, staying asleep, getting out of bed)
Eating difficulties (example: changes in eating habits, appetite, vomiting, binge eating)
Relationships (Family, friends or romantic relationships)
Self-confidence
Bullying/ Physical or verbal abuse
Sexual abuse/ harassment
Drugs or substance use
Self-harm
Suicidal thoughts
Other
Please tell us how urgently you feel you need to speak to someone Please note that a mental health emergency is a life threatening situation in which someone is a danger to themselves or others or someone struggling with suicidal thoughts
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Urgently
Non-urgently
Please describe your emergency:
I am experiencing thoughts of ending my life or seriously harming myself
I am concerned that someone else's life or safety is at immediate risk
I am unable to keep myself or others safe right now.
I understand that an "Urgently" means that I acknowledge that I am experiencing either suicidal thoughts or my own safety or others is at risk.
*
I acknowledge and understand
Please note, that the urgently doesn't mean a quicker meeting but will help us understand the best way to support you immediately, possibly directly contacting your or your emergency contact.
Please note: this service is not intended for students experiencing thoughts of immediate self-harm or suicide. If this is the case, students must contact their local doctor and/or family members and/or a local hospital as a matter of urgency. You can also ask the Student Hub for recommended specialists.
Choosing the option "Urgently" will lead to the following
*
You will NOT get an access to the booking system
You will be directly contacted via email if we don't hear back from you, we will then phone call to assess your emergency
If we couldn't reach you we might need to contact your emergency number
Please tell us how you think your concerns are impacting your daily life?
*
Slightly
Moderately
Severely
Please tell us briefly about any impacts on your daily life, social functioning and academic life?
*
0/200
Have you received any previous counselling or psychiatric help?
*
Yes
No
Which kind of service you receive and by whom?
0/200
How did you know about us?
*
Self-referred/found information on website
Referred by Faculty
Referred by Friend
Referred by Disability & Special Education Service
Other
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Disclaimer and consent
Please note: this service is not intended for students experiencing thoughts of immediate self-harm or suicide. If this is the case, students must contact their local doctor and/or family members and/or a local hospital as a matter of urgency. You can also ask the Student Hub for recommended specialists.
*
I understand
Please note: That during your first session you will receive a counselling consent form that you will need to sign to receive the service
*
I understand
Signature (Please write your full name):
*
Date
Submit
Should be Empty: