University of Leeds Student Counselling Centre Self-referral Form

Please note this counselling service is only available to students who are registered at The University of Leeds.

Welcome to the Student Counselling Centre Self-Referral Form.

Please complete this form if you'd like to attend the Student Counselling Centre for an appointment. When we have received it, we will email you on your University email address, to invite you to book an appointment.

The questions on the first part of this form are designed to help us to book an appointment for you and to provide anonymous data for our statistics. The questions on the second part of the form are designed to help start the counselling process.

Data Protection: We ask permission to keep confidential case records for three years in conformity with the Data Protection Act 1998. This information is kept securely and is only accessible to Counselling Centre staff apart from in exceptional circumstances where a breach of confidentiality might be necessary if a counsellor believes you will cause serious physical harm to others or yourself. Even in this instance, the counsellor will endeavour to discuss with you first the need to break confidentiality.

All information on this form is confidential to the Student Counselling Centre. This questionnaire is located on a secure server and is encrypted. The Web address begins with https and has a small padlock icon showing you that the connection is secure. Any answers that you provide on this questionnaire will also be encrypted.

This form will take you about 20 minutes to fill out; you may wish to find somewhere private to complete it. Please use the 'Submit and continue' button at the bottom of each page to navigate through this form. Once you have clicked on this button you won't be able to return to your answers. Your answers are automatically submitted as you go through the form.

If you submit your answers you will not be able to return to this page.