Page 1: About this Form and Our Service


If you are experiencing emotional, psychological, or mental health difficulties that are affecting your studies, work, health, relationships or wellbeing, you may benefit from some support to get back on track.  The Counselling and Mental Health Team provides a welcoming, supportive, safe and confidential space where everyone is treated with dignity and respect.

Please read the following for more information about our service and this referral form.  We appreciate there is a lot of information but it is important and we hope it will save you time or any misunderstanding in the long run. 

You do not need to fill out a self-referral form for the following (information about all of these situations can be found below):

  • You are in immediate crisis and need emergency assistance.
  • You want to attend a single session workshop.
  • You are enquiring about DSA Specialist Mentoring.
  • You are only seeking mitigating circumstances evidence but have not seen a counsellor or mental health advisor on 3 occassions recently.

About Completing this Self-Referral Questionnaire

Completing this online questionnaire is your first step in the process of self-referral to the Counselling and Mental Health (CMH) Service. If you are struggling to complete the questionnaire, please contact us via email at to discuss your situation.

Some of the questions are purposely quite involved to help you to explore your current concerns and hopes in preparation for an appointment with our service, and although some of the questions may feel very personal and difficult to answer, please complete as much as you can, ensuring you only state as much as you feel comfortable with.  The questionnaire usually takes about 20-30 minutes to complete but you are welcome to take longer if you want to use it as an opportunity for reflection and self-discovery.

If you want to save and finish this questionnaire later, please use the Finish Later button at the bottom of each page, this will give you instructions on how to bookmark the page so you can come back to it at a later time.

On the last page of the questionnaire you will be given the opportunity to Submit your answers.  Once submitted, your completed questionnaire will be reviewed by a member of the CMH team and you will be contacted (via email or phone) to be offered an individual initial assessment appointment with one of the Counsellors or Mental Health Advisors.

The Self-Referral Questionnaire is split into 4 main sections:

  1. Questions about you, your contact details, availability and demographic information.
  2. Questions about any current or past psychological or mental health support you may have had.
  3. Questions to help you think about the difficulties and concerns you are facing and what you might want to get from Counseling or Mental Health Advice.
  4. Questions about your current mental health risk.

In a Crisis Now?

As the University Counselling and Mental Health Service is not an emergency service, if you feel that you are in immediate crisis, and you are thinking of seriously harming yourself or ending your life, please speak to your GP, go to the local A&E, ring the NHS Helpline 111 or call the Samaritans on 116 123. 

If you have thoughts about harming yourself or ending your life but do not feel you are at immediate risk, please do contact us, by completing this self-referral form as best you can, so we can support you at this difficult time.  We also strongly recommend you see your GP as soon as possible.

Want to Attend a Workshop?

If you are interested in attending one of our single session wellbeing workshops, you can just book yourself in here  More information about the workshops are available here

Seeking DSA Specialist Mentoring

If you are entitled to Specialist Mentoring or would like more information about the Disabled Students Allowance (DSA) please do not complete this form but rather email us at

Our service is a provider of Specialist Mentoring (for Mental Health Conditions and Autism Spectrum) which is funded for students through the Disabled Students Allowance (DSA).  We work with students to help them overcome barriers to success associated with their mental health difficultly or neuro-developmental conditions such as ADHD and Autism Spectrum Disorders, to provide them with a more equal chance of achieving both their academic and personal goals.

Seeking Evidence for Mitigating Circumstances?

If you are seeking evidence for Mitigating Circumstances, please be aware that since any student can request an appointment with either a counsellor or a mental health advisor at any time, attendance does not in itself mean that we would automatically support a student's case for mitigating circumstances, as we may be discussing issues that do not seriously affect the ability to study. 

Before agreeing to provide a letter of evidence, we must be able to make a reasonable assessment of how the student's circumstances have affected him/her.  To do this we need to have knowledge of the student over a period of time, and not just to have met on one occassion.  As a general rule, we require that the student will have met with their Counsellor or Mental Health Advisor on at least three occassions, and close to the period in time for which he or she wishes to establish that the study was affected.  Even when we have seen a student on several occassions, we may not feel able to provide evidence that their circumstances have affected their ability to study.