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Appointment Request Form

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Your life generally
Your studies
NO YES: but NOT within the last two weeks (please provide details below) YES: within the last two weeks (please provide details below)
Thoughts of ending your life
Alcohol and drug use
Fears of being harmed by others
Thoughts of harming others

If you are currently feeling unsafe or in crisis, please see the following for sources of crisis support:
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Privacy statement
By submitting this appointment request form you understand that you are consenting that we will hold your personal data. 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 information is securely held by Wellbeing Support Services and will be treated confidentially and appropriately for the purposes of carrying out the ongoing business of Wellbeing Support Services under the terms of the Data Protection Act 2018 and General Data Protection Regulations (GDPR). We use your data to plan the most appropriate support, this may involve sharing information within Wellbeing Support Service departments. The professionals within the department have external supervision to ensure that they can offer you the best practice. Your anonymised data may be used for planning future service. If there is a significant risk identified, or when required by law your information may be shared with external agencies but consent to release data is sought if at all possible. Please see the 'Appointment Information' section of our website and the University's Data Protection Policy for more details:
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