Counselling and Mental Health Self-Referral Form

Counselling and Mental Health Self-Referral Form
Basic information
Name*

First NameLast Name
Birthdate*

DayMonthYear
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 processed with the booking*

NameRelationship to student
Emergency contact telephone number*
Living Status*

With parentsBUE Residence (Dorms)Other dorms/residenceAlone or with roommatesOther
Course details
Faculty & Programme*
Year of study:*

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
Should be Empty:

Basic information