Use this form to confidentially request Wellbeing support for a student.
Student full name *
Student ID number *
Student age *
Student contact telephone/mobile number *
Student gender * MaleFemaleOther
Student course of study *
Nature of the worry indicated by the student *
Your name *
Your email address *
Your telephone number (inc. extension) *
Which campus are you based at? * Please select:Balliol Road CampusSouth Sefton CampusThornton CollegeSt Winefride's Campus
By ticking this box, I can confirm that the student I am referring to the Counselling Service has given me their full consent to being referred and therefore being contacted by the Counselling Team.
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