Thank you for requesting support from the Counselling & Wellbeing team. We need to ask you a few questions to help us identify you and your needs. The first part of this form is personal details. Then next part is about your data and consent.

Part 1 - Personal Details

*First Name *Last Name *Student Number *Mobile Number Home Telephone *Term Time Address (including postcode) Have you used the service before? Yes No

*Do you consent to be contacted by Student Services via: Mobile Home phone SMS University Email

*What is your preferred method of contact? Mobile Home phone SMS University Email

*Please briefly describe any current difficulties you are facing? (Max 500 characters)

PART 2 - Data and Consent

The Student Wellbeing Services value your privacy and store your information in a responsible manner, for more information please review our University Data Policy. If you do not consent to any sharing please enter 'no' in each of the consent boxes.  Please refer to Data protection rights for more information.

If you have any concerns about the use s of your data you can contact our Data Protection Officer at imps@reading.ac.uk or by telephone on 0118 378 8981.

Consent to share with:

Please confirm if you allow us to talk to other support contacts within Wellbeing Services & the wider University

*Hall Wardens Yes No Prefer not to answer *Disability Advisory Services Yes No Prefer not to answer *The Welfare Team Yes No Prefer not to answer University of Reading Staff (i.e. Personal Tutor) Yes No Prefer not to answer

Consent to talk to others if required:

Please confirm if you allow us to talk to support contacts outside of the University

Supportive Practitioners / Agencies (i.e. NHS/Social Services Yes No Prefer not to answer Doctor (GP) Consent Yes No Prefer not to answer Next of Kin Yes No Prefer not to answer Supportive Friend Yes No Prefer not to answer

Doctor (GP) Information

Please enter details of your Doctor (GP) Surgery

Doctor (GP) Surgery Name Doctor (GP) Surgery Address Doctor (GP) Surgery Contact Number

Next of Kin / Supportive Friend Information

Please enter details of your Next of Kin or Supportive Friend

Next of Kin Name Next of Kin Address Next of Kin Contact Number

Supportive Friend Name Supportive Friend Contact Number