Student Wellbeing Self-Referrals
Please tick to confirm that you are a current student at Bournemouth University, agree to the Consent and Confidentiality Agreement (available on the Student Wellbeing BU web-page) and wish to register with Student Wellbeing:*
Yes
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
Lady
First Name:*
Last Name:*
Date of Birth:*
Gender:*
Male
Female
Other
Not known
Term time House Name/No:*
Term time address:*
Town/City:*
County:*
Term time Postcode:*
Email:
Mobile Number:*
Can an SMS be sent to this number?:*
Yes
No
Can a voicemail be left on this number?:*
Yes
No
If not, how may we contact you?:
Are you registered with Talbot Medical Centre?:*
Yes
No
If you answered "no" please provide GP details below.
GP Surgery Name:
GP Surgery Address:
Ethnicity:*
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black backgrond
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - I do not wish to state
Not known - Not known
Sexuality:
Please Select A Value...
Heterosexual
Homosexual / Lesbian
Homosexual / Gay
Bisexual
Asexual
Other
Declined to Respond / unknown
What faculty do you belong to?:*
Please Select A Value...
Bournemouth University Business School
The Faculty of Health and Social Sciences
The Faculty of Media and Communication
The Faculty of Science and Technology
Other
Which year of university are you currently in?:*
Please Select A Value...
Year 1
Year 2
Year 3
Year 4
Placement Year
Masters
PhD
Where are you located for lectures?:*
Lansdowne
Talbot
Other
If "other" please specify:
Who referred you to the service?:*
Myself
BU staff (tutor)
BU staff (other)
Doctor
Other
If "other" please specify:
Have you made contact with this service before?:*
Yes
No
How did you hear about us?:*
Where would you prefer to have your appointments?:*
Talbot Campus
Lansdowne Campus
Telephone/ video consultations
Please give a brief descriptions of any problems that have led you to seek help:*
When did your difficulties start?:*
Please provide details if you have ever sought any counselling, psychological or psychiatric help before:
Is there anything else you would like us to know at this stage?:
Please tick to indicate if you are happy for the student wellbeing service to share information with:
Student services
Wider university staff (including course team)
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