Partner accommodation referral form

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Please complete this form to share any serious concerns you may have about a student's wellbeing.

The form can be completed by anyone who has concerns about a student who may benefit from wellbeing support.

Once submitted the information will be reviewed by a Health and Wellbeing Practitioner and appropriate action taken. We will contact you if we need more detail.

Please also note that this referral will be viewed and actioned during the Wellbeing and Student Support standard office hours being Monday to Thursday 9am – 5pm or Fridays 9am to 4.30pm. IF URGENT SUPPORT OR ADVICE IS REQUIRED PLEASE CALL THE EMERGENCY SERVICES AND/ OR COMMUNITY SAFETY TEAM.

REFERRER'S DETAILS

Contact telephone number of the referer

Email of the referer

Job role of the referer

STUDENT'S DETAILS

Full name

University ID

Email address

Phone number

Current Address

Country

Risk of serious harm to self or others

Mental health issues

Erratic/concerning behaviours

Sexual/domestic abuse

Severe anxiety/distress

Other

If you consider there are any immediate risks evident, please provide details (and consider contacting the Emergency Services and/ or Community Safety Team)

Please provide a brief description of the concerns or issues prompting this referral. Include any relevant observations, dates/times, locations or incidents

Signposted student to Wellbeing and Student Support

Spoken with the student and discussed concerns (either in person or video call)

Seen the student in person and discussed concerns

Shared concerns with others

Are you aware if the student has accessed and engaged with any professional support or advice previously or is currently accessing support? (if Yes – please provide any details)

Are you aware if the student has any vulnerabilities, disabilities or health related needs? If yes please provide details.

Is the student aware that you are raising this referral?

After you click 'send form' this form will be submitted to Wellbeing and Student Support.

A Wellbeing Practitioner will review the details and take appropriate action. We will contact you if we need more detail.

Thank you.

Privacy notice

The information on this form will be used to offer support to students at the Univeristy. The data you provide will be treated sensitively but is not anonymous.

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.

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