Partner Provider Notification 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.

If your referral is URGENT or needs an immediate response, please contact Emergency Services.

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 be aware that this referral will be viewed and actioned during the Wellbeing and Student Support standard office hours - Monday to Thursday (9am to 5pm) and Friday (9am to 4.30pm).

REFERRER'S DETAILS

Name of Accommodation

Full name

Contact telephone number

Email of the referrer

Job role

STUDENT'S DETAILS

Full name of Student

University ID

Email address

Phone number

Current address

Risk of serious harm to self or others

Mental health issues

Erratic/concerning behaviours

Sexual/domestic abuse

Severe anxiety/distress

Other

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

Signposted the 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

Contact Emergency Services if appropriate

Are you planning on taking any further action yourself

No action taken to date

Other

Are you aware if the student has accessed and engaged with any professional support or advice previously or is currently accessing support? Please provide any relevant details below.

Is the student aware that you are raising this referral

When you click 'send form', the form will be submitted to Wellbeing and Student Support.

A Health and Wellbeing Practitioner will review the details and take appropriate action.

We will contact you if we need more detail. Thank you.

Privacy notice

This form is anonymous. No data which personally identifies you is collected on the form, and the data you provide is used solely to help us improve the delivery of our courses.

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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