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Appointment Request Form

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The following questions will help us to ensure that you receive the right level of support.
Over the last two weeks, how often have you been bothered by any of the following problems?

Over the last two weeks, how often have you been bothered by any of the following problems?

If you are concerned that you cannot keep yourself safe, please do seek immediate support.
Sources of immediate support can be found here:
https://warwick.ac.uk/services/mentalhealth/crisis
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Because of my current mental health/wellbeing difficulties my ability to study is impaired.
Because of my current mental health/wellbeing difficulties my home management (e.g. cleaning and tidying; cooking and paying bills) is impaired.
Because of my current mental health/wellbeing difficulties my social leisure activities (with other people e.g. parties and outings; visits and home entertaining) are impaired.
Because of my current mental health/wellbeing difficulties my private leisure activities (e.g. reading and walking alone and other hobbies) are impaired.
Because of my current mental health/wellbeing difficulties my ability to form and maintain close relationships with others including those I live with is impaired.
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Privacy statement
The information you provide on this form will be used by Wellbeing Support Services to process your request for an appointment and for the provision of support. Your data is processed in accordance with the Data Protection Act 2018 and the University of Warwick's Data Protection Policy. Confidentiality and information sharing will be discussed with each student when they meet with a member of the Mental Health and Wellbeing Team and you will be asked to complete our consent to share information form. Please see the 'Appointment Information' section of our website and the University's Data Protection Policy for more details: https://warwick.ac.uk/services/mentalhealth/appointments https://warwick.ac.uk/services/idc/dataprotection/
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