Online Referral Form

Please make sure you fill in all relevant fields, otherwise we may not be able to contact you:

Name

Roll Number

Telephone Number

Email

Service(s) which I'd like to access:

Wellbeing Support

Counselling

Mental Health Support

Reason for self referral (please give as much information as possible):

By ticking the box below I give my permission to be contacted by the Counselling and Wellbeing Service with regards to gaining feedback around the service and support I received. I understand that by ticking this box I consent to receive details, via e-mail, of any current research or evaluation of the Counselling and Wellbeing Service. I understand that participation is voluntary, that the surveys will not be identifiable and that I have the right to withdraw from receiving any further correspondence.

By clicking send I agree to the Counselling and Wellbeing Service contacting me by either email or phone.  I also confirm I have read the terms and conditions at the following address http://www.advice.salford.ac.uk/page/counselling and if I am accessing counselling I can meet these. You will be contacted within 2 working days.