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
What faculty do you belong to?:*
Please Select A Value...
Science and Technology
Media and Communication
Health and Social Services
Management
School of Combined/ Joint Honours
Graduate School
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)
Please complete the captcha
Submit
Cancel