Self referral form | Heriot Watt University Health and Wellbeing Service

Heriot Watt University Health and Wellbeing Service

Welcome to the Heriot Watt Student Counselling Service

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Student Number *

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Campus *

First Name *

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Last Name *

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Date of Birth *

HWU Email Address *

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Address Line 1 *

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Address Line 2

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Address Line 3

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Town/City *

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Post Code *

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Mobile Phone Number *

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Voice Mail Mobile *

Yes

School *

Year of Study *

Level of Study *

Mode of Study *

Referred by *

Please give a brief description of why you would like to see us. *

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Have you used this service before? *

If you are registered with the University Medical Centre please select it here

Name and address of your GP if you have not selected the University Medical Centre above

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I accept terms and conditions. *

Contact Telephone: 0131 451 3386