Register for Online Counselling

Please make sure you have read the section “Who is Online Counselling for?” before you complete the registration form. We do not offer this service to people who we believe could access our face to face services but choose not to.

 

Please provide the following information as completely as possible.

Do you have access to a computer that will be uninterrupted for 50 minute periods?
Yes No

Do you have an email address that can be accessed only by you? If not, would you be willing to create one?
Yes No

Are you aware of any 3rd party with a vested interest in intercepting or accessing communications to your email inbox?
Yes No

Where are you writing from?
Town/City/Village
Country
If you are writing from Leeds or West Yorkshire, please could you briefly state your reason for seeking our Online Counselling Service rather than using our face to face service. If you are applying from these areas but do not complete this section your application will be automatically rejected.

Forename(s)
Surname(s)
Student ID Number
Date of Birth

Have you used the Student Counselling Centre Before?
Yes No
If 'yes' who did you see?

Department

Course

Tutor

Year of course: (1st, 2nd, etc)

Term Address

Telephone *

Mobile Phone Number *

* We require these numbers to comply with good practice guidelines.

Email (must be only accessible by you)

Home Address

Home Telephone (if different from above)

Can we write to you at your term time address?
Yes No

Can we write to you at your home address?
Yes No

Can we phone you at your home number?
Yes No

Can we leave a message on your mobile phone?
Yes No

Can we leave a message at your home number?
Yes No

Emergency Contact Details for applicants from within the UK
Name of Emergency Contact

Telephone Number of Emergency Contact

What is their relationship to you?

Emergency Contact Details for applicants from outside the UK
Please note we will not offer Online counselling to anyone who does not provide us with appropriate emergency contact details. We require either the contact details of your English speaking GP/Health Provider where you are or those of your English speaking Tutor/Departmental contact where you are.
My emergency contact number is:
My GP / Health Provider where I am
Name

Telephone Number

Email address:
My Tutor / Departmental contact where I am
Name

Telephone Number

Email address:
I confirm my Tutor / Health Provider Speaks English
I confirm my tutor / Health Provider has agreed to act as a point of emergency contact

Nationality

Ethnic Origin

(Other)

Counselling Suggested By

(Other)

Disability

(Other)

I am registered with the Leeds Student Medical Practice
I use a different UK GP (please enter full contact details)

I am registered with a GP/health provider abroad - please enter FULL contact details.
(We do not usually offer the Online Counselling service to anyone who had not arranged appropriate medical support where they are. Sometimes, where this has not been possible, we will accept the details of an English speaking Departmental contact where you are. We need this information to satisfy health and safety requirements in the event of a medical emergency.)

All the information I have provided is true to the best of my knowledge. I have read, understood and agree to abide by the information about the Student Online Counselling Service on this site.

When you click the "Submit Registration" button, you will receive an e-mail with a confirmation link which you must click to proceed with the registration.

When we receive your registration request, we will respond to you via e-mail typically within 5 working days. If you have not heard from us within 7 days please contact us at stucouns@adm.leeds.uk. Thank you.