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Request Wellbeing Support
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About you
How we use your information
By submitting this form, you are consenting to this information being shared with staff who can provide you with support. However, depending on what you have written, we may also need to share information with others. At registration, students can choose to ‘opt-in’ to a policy that allows us to contact your nominated emergency contact if we have a significant concern about your welfare. This is explained in the
Student Emergency Contact Procedure
. We will always try to discuss this with you first. In an emergency we can contact your nominated emergency contact regardless of whether you have 'opted in' to this policy. For example, if we believe you are at risk of harming yourself or others, we are obliged under our duty of care to override confidentiality. Depending on the urgency of your situation, we may not be able to discuss this with you first. Further information including a list of University services that operate in this way can be found in the
Education and Student Experience Division Confidentiality Statement
.
By submitting this form, you are consenting to this information being shared with staff who can provide the student with support. However, depending on what you have written, we may also need to share information with others. At registration, students can choose to ‘opt-in’ to a policy that allows us to contact their nominated emergency contact if we have a significant concern about their welfare. This is explained in the
Student Emergency Contact Procedure
. We will always try to discuss this with the student first. In an emergency we can contact their nominated emergency contact regardless of whether they have 'opted in' to this policy. For example, if we believe they are at risk of harming themselves or others, we are obliged under our duty of care to override confidentiality. Depending on the urgency of the situation, we may not be able to discuss this with the student first. Further information including a list of University services that operate in this way can be found in the
Education and Student Experience Division Confidentiality Statement
.
Request Wellbeing Support
Thank you for requesting support. Your form will be reviewed before the end of the next working day. If you need support before this, please view our
emergency support page
.
If your situation changes or you have any further important information you want to tell us about, please call Wellbeing Access on +44 (0)117 456 9860 or email
wellbeing-access@bristol.ac.uk
.
Thank you for requesting support. Your form will be reviewed before the end of the next working day. If you need support before this, please view our
emergency support page
.
If your situation changes or you have any further important information you want to tell us about, please call Wellbeing Access on +44 (0)117 456 9860 or email
wellbeing-access@bristol.ac.uk
.
Complete this form to request wellbeing support for yourself or a student at the University.
If you need help completing the form, please call Wellbeing Access on +44(0)117 456 9860 or email
wellbeing-access@bristol.ac.uk
.
For urgent and emergency care
Do not use this form. Call 999 immediately or
go to your nearest hospital
. After calling 999, if you are on Campus call Security Services on 0117 3311223.
Who are you requesting wellbeing support for?
I am completing this form because:
*
I am completing this form because:
I am requesting support for myself
I am completing this form because:
I am requesting support for someone else
I am completing this form because:
I am a staff member requesting support for a student
Are you a member of staff in Wellbeing Access, Residential Life or the Student Wellbeing Service, completing this form on behalf of a student?
Are you a member of staff in Wellbeing Access, Residential Life or the Student Wellbeing Service, completing this form on behalf of a student?
No
Are you a member of staff in Wellbeing Access, Residential Life or the Student Wellbeing Service, completing this form on behalf of a student?
Yes
Are you a University of Bristol student?
Are you a University of Bristol student?
No
Are you a University of Bristol student?
Yes
Are you currently in the Bristol area?
Is the student currently in the Bristol area?
Are you currently in the Bristol area?
Is the student currently in the Bristol area?
No
Are you currently in the Bristol area?
Is the student currently in the Bristol area?
Yes
Please tell us which city, region and/or country you are in now, as this may affect the support we are able to provide.
*
First name
*
*
Last name
*
*
Pronouns
She/her
He/him
They/them
Ze/zir
No preference
Name only
Other pronoun not listed / Option for the student to specify
Email
*
*
*
UK mobile phone number
*
Any other home/personal number you use (include international dialing code if outside the UK)
*
Student number
*
Your student number is a 7 digit number that you can find on the back/front of your University ID (UCard). For example, 1234567. If you do not know what your student number is you can find it by logging in to Student Info.
Help us to help you get the right support
Are you worried about your emotional wellbeing?
Are you worried about your emotional wellbeing?
No
Are you worried about your emotional wellbeing?
Yes
If you are not worried about your emotional wellbeing, please tell us why you are getting in touch
*
What has caused you to reach out for support? (Select all that apply.)
Exams or academic work
Relationship worries
Victim of crime or sexual violence
Bereavement or loss
Feeling lonely or isolated
Bullying / harassment
Victim of discrimination
I feel at risk from someone else
Other
Concerns about my mental health
Concerns about my physical health
What has led to you to reach out for support? Opts
*
Please give some details
*
Do you have a diagnosed condition? (Select all that apply.)
Mental health condition
Physical or medical condition
Specific learning difficulty eg dyslexia
No
Other
Do you have a diagnosed condition? Opts
*
Please give details of your diagnosed condition
*
Are you using drugs or alcohol to help manage your problems?
Are you using drugs or alcohol to help manage your problems?
Yes
Are you using drugs or alcohol to help manage your problems?
No
Are you using drugs or alcohol to help manage your problems?
Prefer not to say
Have you had any thoughts about hurting yourself or others?
Have you had any thoughts about hurting yourself or others?
No
Have you had any thoughts about hurting yourself or others?
Yes
For each of the following, please say when this happened most recently - if ever:
I have hurt myself physically or taken risks with my health
I have hurt myself physically or taken risks with my health
Never
I have hurt myself physically or taken risks with my health
Over a year ago
I have hurt myself physically or taken risks with my health
Within the last year
I have hurt myself physically or taken risks with my health
Within the last month
I have hurt myself physically or taken risks with my health
Within the last week
I have hurt myself physically or taken risks with my health
Within the last 24 hours
I have thought it would be better if I were dead
I have thought it would be better if I were dead
Never
I have thought it would be better if I were dead
Over a year ago
I have thought it would be better if I were dead
Within the last year
I have thought it would be better if I were dead
Within the last month
I have thought it would be better if I were dead
Within the last week
I have thought it would be better if I were dead
Within the last 24 hours
I have made plans to end my life
I have made plans to end my life
Never
I have made plans to end my life
Over a year ago
I have made plans to end my life
Within the last year
I have made plans to end my life
Within the last month
I have made plans to end my life
Within the last week
I have made plans to end my life
Within the last 24 hours
I have made an attempt on my life
I have made an attempt on my life
Never
I have made an attempt on my life
Over a year ago
I have made an attempt on my life
Within the last year
I have made an attempt on my life
Within the last month
I have made an attempt on my life
Within the last week
I have made an attempt on my life
Within the last 24 hours
I have threatened to or thought about hurting another person
I have threatened to or thought about hurting another person
Never
I have threatened to or thought about hurting another person
Over a year ago
I have threatened to or thought about hurting another person
Within the last year
I have threatened to or thought about hurting another person
Within the last month
I have threatened to or thought about hurting another person
Within the last week
I have threatened to or thought about hurting another person
Within the last 24 hours
Other
Other
Never
Other
Over a year ago
Other
Within the last year
Other
Within the last month
Other
Within the last week
Other
Within the last 24 hours
Please describe your thoughts about hurting yourself or others
*
Do you currently have any support? (Select all that apply.)
Family
Friends
Counsellor/therapist
NHS mental health services
Mental health worker
Doctor
I currently have no support
Other
Do you currently have any support? Opts
*
Is there anything more you can tell us about your existing support?
*
Do you feel there are parts of your life you are managing well?
My academic work
My relationships
My exercise routine
My self care eg eating, sleeping, personal hygiene
I do not feel I am managing anything well
Other
Do you feel parts of your life managing well Opts
*
Is there any more you can tell us?
*
Please use this box to tell us more about why you are requesting support. The more information you can give the better we can help you. If other people are involved, please do not give specific names here.
*
About the student requiring support
What is your relationship to the student requiring support?
*
Student’s first name
*
Student’s last name
*
Pronouns
She/her
He/him
They/them
Ze/zir
No preference
Name only
Other pronoun not listed / Option for the student to specify
Student Number, if known
*
Please provide as many of these details as you can (this means we can be sure we have the right person)
Mobile phone
*
Home phone
*
University of Bristol email
*
*
Date of birth
*
Please tell us which city, region and/or country they are in now, as this may affect the support we are able to provide.
*
Does the person you're worried about know you're contacting us? (If not, this may impact on what we can do to help)
Does the person you're worried about know you're contacting us? (If not, this may impact on what we can do to help)
No
Does the person you're worried about know you're contacting us? (If not, this may impact on what we can do to help)
Yes
Tell us why you are worried about them now. Please provide any useful information about their history which may be helpful and tell us about any help you have tried to give. The more information you can give us, the better we can help them. If other people are involved, please do not give specific names here.
*
We may need to contact you if further information is required. Please let us know if there is a preferred time for us to call? We will try to call when you have indicated but may have to call at another time. (Select all that apply.)”
Morning
Afternoon
Evening
Preferred time for us to call? Opts
*
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