Student ID Number * (required)

Full name * (required)

Date * (required)

Personal Tutor * (required)

Please describe the problem that has led to this self-referral. * (required)

How long has the problem been present? (please be specific about the timeline) * (required)

Please describe what you have done to try and resolve this problem e.g. whom you have seen, outline any solutions or treatments. * (required)

Please give details of the current situation and time frame for any likely resolution. * (required)

Please explain how this problem has or may affect your studies. * (required)

Please include any additional documents e.g. GP letter or reflection

Attach file

Privacy notice

The University of Warwick will process your HWP and FtP personal data provided on this self-referral form for supporting you in your studies. The legal basis for processing this personal data is that it is necessary for the performance of a contract. This data will be used in relation to HWP issues and FtP concerns and will not be shared or disclosed to any third parties external to the University of Warwick except when you have been considered by the WMS FtP Committee. In this case, your data will be shared with the GDC. If your data needs to be shared or disclosed with other external third parties in relation to FtP concerns, for example, your employer or medical professionals, your written consent will sought to do so. Your HWP and FtP data will not be transferred outside of the European Economic Area and will be kept securely by the University of Warwick for two years after graduation from the course. If you permanently withdraw from the course without an award, your HWP and FtP data will normally be retained for twelve months after a completion of procedures letter has been issued following any unsuccessful appeal. The University of Warwick is the Data Controller of this information and is committed to protecting the rights of individuals in line with Data Protection Legislation. Please visit the University’s Data Protection webpages for further information in relation to your rights and how the University processes your personal data. The University’s Data Protection Officer (DPO), can be contacted through DPO@warwick.ac.uk and any requests or complaints should be made in writing to the University’s DPO.

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at infocompliance@warwick.ac.uk.