Counselling Form

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You have been sent this form because you have been referred to the University Counselling and Psychotherapy Services.

Please complete this form in order to

help us allocate your counselling next steps, and
help you prepare for your counselling

After you have submitted this form, we will be in touch with you about your next steps: usually this will be details of your counselling appointment. Please note that if you have recently used the service, it may be more appropriate for you to take some time to consolidate the learning from your therapy than to restart immediately.

Full name

Uni ID number

Please provide your telephone number. Most of our contact with you will be via messages through the Wellbeing portal, but we may contact you by a phone call in exceptional circumstances (for example, to confirm appointment details).

Yes, I have read the ‘Preparing for Therapy’ information.

Yes, I have read the Counselling and Psychotherapy Overview and FAQs.

I understand that if I need urgent intervention, I will contact the relevant service. Find a range of resources if your need is immediate or urgent.

Yes

If you have had counselling before (anywhere), please briefly outline what was useful (if you have not had counselling previously, please leave this blank)

In brief, please outline your specific therapy goal, what key aspect you particularly want to work on/achieve through therapy?

To help us offer you the most appropriate intervention, please tell us, over the last two weeks:

Sometimes/often

Not at all

Occasionally (e.g. fleeting thoughts once or twice)

Most or all of the time (i.e. several times every day)

*The Counselling Service does not provide emergency support, and your responses to this form will not be seen immediately. If you feel at immediate risk of harm or require immediate emotional, psychological or mental health support, please see our emergency contacts and other helpful resources.

Impact of your issues. This grid helps consider the level of impact caused by the issues you may want to explore in therapy:

The level of impact

strongly disagree

disagree

neither agree nor disagree

agree

strongly agree

My issues are having an impact on my ability to manage my academic work

My issues are having an impact on my wellbeing

My issues are having an impact on my mood

My issues are having an impact on my self-esteem

My issues are having an impact on my ability to manage difficult feelings

My issues are having an impact on my relationships with others

I am considering leaving university (permanently or temporarily) because of my issues

Overall I am enjoying my time at university

I am developing skills at university that might be useful in obtaining future employment (eg increased confidence; assertiveness)

I am able to have an appointment either on screen (ie online via MS Teams) or in person on campus

I need to have my appointment in person (as I don’t have an appropriately private space I can use for an appointment)

I need to have my appointment on screen (online via MS Teams, because, for example, I am away from campus)

I would like to have Email Therapy

Thanks for taking time to complete this form.

After you click 'submit' you will get a copy of your completed form sent to your inbox (if you were logged in to your Warwick email account).

We hope to be in touch with you within approximately 2 weeks after you submit this form, but during very busy periods, this may be a little longer.

IMPORTANT Please look out for an email alert to a message that will let you know the details of your next steps, such as the date and time of your counselling appointment. You will need to respond to an appointment offer within 48 hours. (NB to access the message you may need to complete the '2 step authentication process')

If you have any other wellbeing-related issues, please call in to Wellbeing & Student Support Reception in Senate House during normal working hours, or come for a brief consultation through the Wellbeing Portal.

Find our contact details on our homepage.

Many thanks.

Privacy notice

The information on this form will be used to help prepare the next steps for your support. The information will be accessible to the University Wellbeing and Student Support Services staff on a 'need to know' basis. The form will be stored for 6 academic years. We will use and store the data in compliance with the University's data protection requirements.

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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