Notifying Concerns to W&SS

Complete this form to notify Wellbeing and Student Support of any serious concerns you may have about a student's wellbeing where you think it may be useful for the University to be aware.

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

This form is not for use if urgent/emergency support is required from the University W&SS.

Name of person making referral

What is your professional role (eg GP, Nurse, etc)

Contact details of person making referral (please include the name of the Health Centre/Practice and the contact telephone number)

Please provide a contact email address

Other/preferred/chosen names

Address or current place of residence (eg if home or abroad/elsewhere, if known)

Student’s telephone number

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

Please provide the date of the last contact with the student and the outcome of the interaction

Has the student consented to you sharing information with the University Wellbeing and Student Support Services?

After you click 'send form' this form will be submitted to the Wellbeing and Student Support email account which is staffed during standard univeristy business hours.

A 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 not anonymous. The data collected will be used to consider the level of wellbeing support from the university for the student identified.

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.