Form

SECTION 1: Personal Details

If you are completing this form as a self-referral into the service, you do not need to complete Section 2 of the form.
If you are completing this form on behalf of a student please complete all sections of the form and please ensure you have the student’s consent prior to submitting this referral.
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 to explore what support may be available from external organisations within the country in which the student resides. This 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 contact details

Student Telephone Number*

The contact details you provide will be used by Life Lounge staff to contact you following receipt of your registration form. If you do not provide an up to date contact number, we will use the contact number provided on your student record.

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.

Students address

Street address

Street address 2

Town

SECTION 2: Referrer Details

If you are completing this referral on behalf of a student, please complete the following details:

Your name

Relationship to the student

Your telephone number

Your email address

Email address of the person making the referral

Has the student consented to this request for support?

Yes

Do you have any current safeguarding concerns?

Yes

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

Yes

If you have ticked yes to current safeguarding concerns, please provide further details, including what actions you have taken to address these concerns:

SECTION 3:

To help us understand your current difficulties, please use the tick boxes below to tell us why you would like to access support from the Life Lounge:

Over the past 2 weeks have you had thoughts that you would be better off dead or hurting yourself in some way?*

Yes

Please use the space below to tell us a little more about your current difficulties and how you feel we can help:*

SECTION 4: Data Protection

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.