Self-Referral Form for Student Counselling, Mental Health or Wellbeing Support

Please take 5 minutes to tell us how we can help you. The more information you provide, the more we can help. We will review your request and contact you to arrange support and/or obtain any further information required.

While you are waiting for support you can attend one of the drop ins and you can visit our website for self-help information.

If you have any questions or difficulties in completing the form please contact us on The Counselling, Mental Health and Wellbeing Team deal with all information provided in a sensitive and confidential manner. Please see the section at the bottom of this form regarding how we use your information, data protection, and UCLan's privacy policy.

All fields marked * are mandatory.

Your Details

We will try to use your preferred method, however we may need to contact you by other means if we need to contact urgently.

Support Requirements

Academic difficulties
Accommodation issues
Alcohol misuse
Care leaver
Caring responsibilities
Domestic violence
Drug/substance misuse
Eating difficulties
Experiencing unusual thoughts
Family related issues
Forced marriage
Friendship related

Hate Incident/Crime (LGBT, Disability, Race, Religion)
Hearing or seeing unusual things
Home sickness
Honour based violence
Inclusion support (Disability)
Personal safety concern
Physical assault
Physical health
Self and identity (LGBT)
Self care
Sexual assault and/or rape
Stalking and harassment
Thoughts of harming others

How we use your information

By choosing to submit an Online Student Wellbeing Referral you are consenting to relevant advisors within Student Services using this information to assess your needs and direct you to the most appropriate form of support. This will include support provided by our Counselling, Mental Health and Wellbeing, Inclusive Support and Financial Support teams. Where we feel that you would be best supported by our external onsite partners, such as MindsMatter and Lancashire Mind, we will seek your consent prior to making a referral.

We may use the content of your report to form the basis of our initial meeting with you. We will also use your data for service monitoring and anonymised reporting on wellbeing referrals for statistical and preventative purposes. If you would prefer not to provide your information using this online form you can contact the wellbeing team on 01772 893020 or email You may also find it helpful to have a look at the support pages on our website

Your information will be kept on our records for six years following graduation or withdrawal, after which the data will be reviewed for destruction. We will not disclose your personal information to any other parties without your consent unless we have safeguarding concerns for you or another person and we believe there is a genuine threat to a person’s health or safety or a risk to life.

For further information about how the University will use your personal information, please see our Privacy Notice.