Form

SECTION 1: Details of student being referred to the Life Lounge [to be completed by all]

If you are completing this form as a self-referral into the service, please complete the following section with your own details. You do not need to complete Section 2 of the form.
If you are completing this form on behalf of a student (for example, you are a University staff member, family member or external professional), please complete the following section with the details of the student you are referring, using as much information as possible.
For students studying outside of the UK the Life Lounge is unable to offer therapeutic support such as Counselling or CBT due to legal and regulatory reasons. Students based overseas who submit a Life Lounge registration form will be contacted by a member of the Life Lounge team, the service provided will be limited to two appointments with either a Wellbeing Coordinator or Mental Health Advisor, the purpose of these appointments is to explore what support may be available to the student from external organisations operating from within the country in which the student resides, these appointments will not be therapeutic support.

Name of Student (being referred)*

Student ID Number (if known)*

Date of birth*

Gender *

Ethnicity*

Sexual Orientation *

Care Experienced/Care Leaver

Yes

Course of study*

Year of study*

Student Telephone Number*

The contact details you provide will be used by Life Lounge staff to contact you following receipt of your registration form. Your mobile number will be used for our appointment text reminder service.

Student University email address *

We will only send email correspondence to your University of Bolton student email account. Please ensure that you check this account regularly.

GP Name, address, contact number and email address *

SECTION 2: Referrer Details

If you are making a referral on behalf of a student, please complete the following details. If you are completing a self-referral please proceed to section 3A.

Name

Relationship to the student

Contacts Telephone Number

Has the student consented to this request for support?

Yes

Do you have any current safeguarding concerns?

Yes

If yes, please use this space to detail your concerns:

Have you reported your concerns to a Safeguarding Lead/ Champion?

Yes

Has a confidentiality/ disclosure form been completed?

Yes

SECTION 3A: Student Further Information

If you are completing a self-referral, please complete the following section. If you are referring on behalf of the student, please complete this section to the best of your knowledge.

Who recommended this service to you?

Have you [or the student] previously accessed any services within the Life Lounge? *

Yes

Please use this space provided to detail any difficulties or challenges you [or the student] are currently experiencing*

SECTION 3B:

Please only complete section 3B if you are a student and you are referring yourself to the Life Lounge.

Do you have a diagnosed mental health condition that you would like to disclose to the University? *

If you have a mental health condition diagnosed by a professional, you may be entitled to further support. If you choose to declare this, you will be contacted by a member of the Life Lounge team who will discuss support available within the university, and will support you in deciding whether you would like other university staff members, such as your tutors etc. to be aware.

Yes

Prefer Not to Say

If yes, please provide details of your diagnosis in the space below:

Which of the Life Lounge Services do you envisage accessing? *

Counselling

CBT

Mental Health Advisors

Has there been a history of emotional or mental health difficulties in the past? *

Yes

Prefer not to say

If you answered 'Yes' please provide some details including whether you have accessed professional help (E.g. Counselling, G.P., Mental Health Service, etc.) or write “N/A” if you would rather not say.

How long have you been facing difficulties?*

What strategies have you used to cope with your current difficulties? *

What would you like to change?*

How do you feel about the future? *

To what extent are you considering leaving your course because of your problems?*

To what extent would you say your problems are affecting your study, e.g. attendance, assessments, etc?*

To what extent would you say your problems are affecting your overall experience at University?*

What medication, if any, are you currently taking for these issues?

SECTION 4: Consent

PLEASE NOTE: Everything you discuss with a member of the Life Lounge team is treated as strictly confidential. However, in order for us to best support you, there may be times that we would need to discuss and share information about your mental wellbeing and or disability related needs with relevant parties.

Below is a list of people/companies we might want to contact during your time studying at the University of Bolton. If you are happy for the Life Lounge to support you in this way, please tick the relevant boxes. Once you have submitted this form one of the team will explain in more detail when we may need to share information.

Funding Bodies (SFE e.g. applying for DSA)

Suppliers and providers of Assessments, Support and Equipment

Medical Professionals, Diagnosticians and other relevant agencies

University Staff (E.g. Academic Tutors and Support Staff)

Family Member

Designated Family Members details

Family Member - Name & Relationship (Optional)

Family Member Email (Optional)

Family Member - Phone (Optional)

I also agree that if I am entitled to Disabled Students’ Allowance and do not make reasonable efforts to apply for this, I may be liable for costs of support incurred which would have been paid for through Disabled Students’ Allowance.*

SECTION 5: Life Lounge Charter and Data Protection

Charter & Data Protection*

Please Click here to download a copy of the Life Lounge Charter document

I have read and agree to the terms documented within the Life Lounge Charter

I have read the Life Lounge Charter and would like to ask further questions about this before agreeing

I have not read the Life Lounge Charter

The information provided in this form will now be used to establish the most appropriate service to meet your needs. A member of the Life Lounge team will be in touch to discuss your registration further and arrange an appointment. We aim to do this within 2 working days. If you have any queries or would like further information, please get in touch with the Life Lounge team.

Please be assured we would only share information that was relevant and necessary. By submitting this registration form you are confirming your consent as identified in this section.

The information held on this registration form is stored in accordance with the University Data Protection Policy. This data is held and processed in accordance with the requirements of the Data Protection Act 1998; 2018.