Counselling and Health Advice request – University of the Arts London

Completing this form

Please complete this form to tell us about why you are contacting the Counselling and Health Advice Service. The information you provide is confidential and helps us to consider what support is appropriate for you.

What happens next

We will aim to contact you within 3 working days.

Please be aware that we also offer virtual drop-in sessions. Short drop-in appointments with members of our team are
available to book every weekday during term-time. Appointments take place on Microsoft Teams. Find out more information and how to book.

It is important to know that the Counselling and Health Advice Service is not an emergency support service. For
immediate help, please see emergency services available to help you.

If you have any difficulty completing this form you can email us at studenthealth@arts.ac.uk (monitored on weekdays, 9am - 5pm.

Privacy Notice

UAL's Student Privacy Policy

Confidentiality

The Counselling and Health Advice Service we provide is confidential and information is kept securely in accordance with the Data Protection Act 2018.

Information will not be disclosed to any person or body outside of the Counselling and Health Advice Service unless:

a - You give consent to do so
b - We are required to do so by law
c - We consider that there is a serious risk of harm to you or someone else

Counselling and Health Advice Service confidentiality policy

Do we have permission to store your data? *

Confirm

I have read and understood the confidentiality policy and the privacy policy. *

Confirm

Name *

Given Name Family Name

Familiar / preferred name

Preferred pronoun

Date of birth *

Student ID *

Phone number *

Preferred email *

Course name

College *

Year of study *

Accommodation *

Are you currently in the UK? *

Yes
No

Country of current residence *

Emergency contact in country of current residence

Name

Given Name Family Name

Relationship to you

Phone number

Please select if living in UAL hall *

Preferred email

Are you registered with a GP? *

Please note that you are expected to be registered with a GP in order to access UAL's Counselling and Health Advice Service. If you are not currently registered we strongly encourage you to register with a GP before your first appointment with us. The Counselling and Health Advice website contains more information on how to register with a GP.

Yes
No

GP Surgery

GP phone / email address

Do you have an existing medical diagnosis? *

Yes
No

Please provide details if you're ok to share this

If you take any medication regularly it would be useful to bring a list of these to your appointment including dosage.

Are you currently receiving support from any of the following?

Counsellor
Psychiatrist
Psychotherapist
Mental health services
Psychologist
Other medical service

Further details

Please tell us more about your problem. *

What kind of help are you looking for? *

How is the problem affecting you? *

If you have any access requirements please provide details in the space below

Have you had any attendance problems this term / year? *

Yes
No

Are you at risk of failing your course? *

Yes
No

Are you considering taking time out from your course or leaving university? *

Yes
No

Are you contacting us to get evidence for extenuating circumstances? *

Please note there is no guarantee that we can provide evidence for Extenuating Circumstances. Please discuss at your appointment.

Yes
No

Can we contact you by email for feedback on our services? *

Yes
No

Would you like to be informed when the Counselling and Health Advice Service holds wellbeing related workshops and events? *

Yes
No