Is the referral for you or someone else?
    Is the individual being referred a student?

    Referrals Information

    What does the individual need support with? (tick multiple options, if necessary)
    Abuse (physical, emotional, sexual or verbal)Anxiety & depressionEating disorderFamily & other relationshipsGender or sexual identityLow self-esteemPersonal developmentPost-traumatic stress (PTSD)Self-harm and/or attempted suicideSeparation issuesSocial anxietyTraumaWork-related issuesOther
    Do you have any medical conditions? (if unsure, leave blank)
    Are you currently on any medication? (if unsure, leave blank)
    Referrers Information

    Relationship/role to the individual

    Creating greater accessibility of counselling and therapy for individuals from
    disadvantaged and low economic backgrounds.

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