Self referral form | Registration with Oxford Brookes Counselling

Registration with Oxford Brookes Counselling

Welcome to the Wellbeing Counselling Service online registration form consisting of six short sections, which need to be completed in one sitting.

Please fill in each section and move to the next section by clicking NEXT, at the bottom of each screen.

Questions marked with an asterisk (*) are required; if you do not fill these in, you cannot submit the form.

Please note that you should complete each section in less than 45 minutes as the section will timeout after 45 minutes.

When you have reached the end of the form, you will be asked to click a button to submit it. We will not receive your referral until you complete the final page and submit the form. Once submitted you will receive an email confirmation.

If you experience any difficulty completing the form, email Wellbeing Reception at wellbeing-recpt@brookes.ac.uk

* Indicates a required field

Student Number *

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First Name *

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Last Name *

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Date of Birth *

Address during semesters - Line 1 *

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Address during semesters - Line 2

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Address during semesters - Line 3

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Town/City *

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Post Code *

Do you have a mobile phone? If Yes, please give the number and if No, please provide an alternative method of contact

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If you do not have a mobile phone please provide an alternative method of contact

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Brookes Email Address *

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Ethnicity *

Gender *

Nationality

Do you consider yourself to have a disability? (please select your primary disability) *

If yes, please tell us if you need assistance for your appointment

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Referred by *

GP Surgery *

Faculty

What course are you studying? *

Year of Study *

Mode of Study *

Level of Study

At which site or campus is your course based?

If other campus, please give details

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I would like to receive a confirmation of the referral to the email address I specified above. Please check the spam folders within your email if you do not receive a confirmation in your inbox.

I accept terms and conditions. *

Contact Telephone: 01865 535222