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

Please complete this form if you would like to make an appointment to discuss your own Wellbeing, Counselling or Mental Health support at the University of Leeds. Please provide as much information as you are able, as your answers help us to understand your situation and direct you to an appointment with the most appropriate practitioner within the team.

If you feel that you need immediate support please read the following:  Emergency Information

Once we have received your form, we will email you at your University email address with further information about booking an appointment.

Data Protection: We ask permission to keep confidential case records for three years in conformity with Data Protection legislation. This information is kept securely and is confidential to Student Counselling and Wellbeing. We will not disclose your registration with our service with any other university staff, friends or family members without your explicit knowledge and permission. The only exception to this is if we believe you will cause serious harm to yourself or others. In this instance, we will always try to discuss the need to breach confidentiality with you first.

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.

The Student Counselling and Wellbeing Service Agreement and Privacy Notice can be read here

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.