Section 1 - Personal Details

*First Name *Last Name *Student Number Pronouns Preferred name (if different from your first name) *Mobile Phone Number *Have you used our service before? Yes No *Are you an international student? Yes No * Where are you currently living? University Halls Private Accommodation At Home *Term Time Address (including postcode)

Section 2: Health Information, accessibility & additional needs

*Do you have any diagnosed or suspected conditions we should be aware of? (e.g. Autism, ADHD, Anxiety) *Are you registered with the University Disability Advisory Service (DAS)? Yes No Unsure *Are you receiving Disabled Students Allowance (DSA) support? Yes No Unsure Do you require any adjustments for appointments? (e.g. online sessions, timing, accessibility needs) *Please indicate any mental health and wellbeing concerns you are currently experiencing (tick all that apply) :- Anxiety (e.g. general anxiety, social anxiety, panic) Low mood or depression Stress (e.g. academic pressure, exams, deadlines) Feeling overwhelmed or burnout Loneliness or social isolation Difficulty adjusting to university life (e.g. Homesickness) Low self-esteem or confidence Relationship or interpersonal difficulties (friends, family, partners) Sleep difficulties Difficulties with motivation, focus, or concentration Identity-related concerns (e.g. cultural identity, sexuality, gender) Financial stress or cost of living concerns Eating difficulties or body image concerns Alcohol or substance use concerns Compulsive behaviours (e.g. gambling, porn) Grief, loss, or bereavement Obsessive Compulsive Disorder (OCD) Traumatic experience(s) Discrimination, harassment or bullying Self-harm Suicidal thoughts or behaviours
*Please tell us a little more about your current difficulties, including any issues not listed and how these are impacting your daily life or studies. *How often are these difficulties impacting your daily activities? Not at all Several Days More than half the days Nearly every day *How long have you been experiencing these difficulties? Recent (past few weeks) Several months Longer-term

Section 3: Your Safety

We aim to review your information and respond within 2 working days, for 24-7 support please use the Wisdom Wellbeing App or 24-hour support line.

If you feel at immediate risk of harm to yourself or others, further Emergency and urgent help information is available here.

In the past month, have you experienced any of the following?

*Thoughts about ending your life by suicide? Not at all Several days More than half the days Nearly every day *Have you ever harmed yourself without intending to end your life? Not at all Several days More than half the days Nearly every day *Are you currently experiencing abuse, violence or feeling unsafe from someone else? No Yes Unsure Prefer not to say *Are drugs or alcohol currently affecting your mental health or safety? No Yes Unsure Prefer not to say *Are you having thoughts about harming someone else? No Yes Unsure Prefer not to say *Do you feel safe at the moment? No Yes Unsure Prefer not to say *Are you currently taking any medication for your mental health? Yes No Prefer not to say Please share anything else you’d like us to know to help keep you safe.

Section 4: Current Support and Goals

*Are you currently (or have you recently) been receiving support for your mental health? (tick all that apply)

Outside of the university GP (doctor) NHS Talking Therapies NHS Community Mental Health Team (CMHT) NHS Crisis Team (CRHTT) Community Support (e.g. No.5, Compass Recovery College, Breathing Space) Private support (e.g. counsellor/therapist)
University-based services Student Wellbeing Services The Student Welfare Team Hall Warden Team Disability Advisory Service
I’m not currently receiving any support
*What changes would you like to see as a result of receiving support from our service?

Section 5: GP Details

*Are you registered with a UK GP? Yes No *GP Name / Surgery *GP Contact Number *GP Surgery Address

Section 6: Consent & Information Sharing

Your information will be kept confidential, unless there is a concern that you or another person is at risk of serious harm, or there is a legal requirement to share information.

Please confirm your consent to the following;

*Sharing relevant information with

*Student Welfare Team Yes No *Hall Wardens/Accommodation Team Yes No *Disability Advisory Service (DAS) Yes No *UoR academic staff and student support coordinators Yes No

Section 7: Is there anything else you would like us to know?

Thank you for completing this form. A member of our team will review your registration and contact you via your university email address. We aim to respond to all registrations within 2 working days.

*Please add your email address here to receive a copy of this form.