Student Wellbeing & Partnership Staff Referral Form

This form should be used if you want to request support from the Student Wellbeing & Partnership team. Before you complete the form we recommend that you have read the guidance document which explains the referral criteria


What to do in an emergency - in an emergency where an individuals safety is at immediate risk of significant harm, contact emergency services on 999. Immediately following this, for any incident occurring on campus, you should contact Security Services on 0121 414 4444 (internally 44444)


Data protection and confidentiality statement

To find out how we will use any personal data you share with us, please read our privacy statements at https://www.birmingham.ac.uk/privacy/index.aspx 

Referrers Details

Name*
Who should we contact if we are unable to reach you?

Student details

Student's Name*
Is this their preferred name?*
This will help us identify the student swiftly
@student.bham.ac.uk
Student's term-time address if known
Is the student under 18
When was your last interaction with the student?
What support is currently in place? (internal & external services)*
Are the issues being considered under any University procedures?*

Additional Information

Is the student registered with a GP?*
Can you identify any actions that would help them?
Have you gained consent from the student to share this information?*
Is the student aware that you have made this referral?

What will happen next?

Once your form has been submitted the relevant team will aim to respond by the end of the next University working day.

Our working hours are Monday - Friday 09:00 - 17:00

Student Wellbeing & Partnership Triage

If you are assigning the case to a College Wellbeing Team or the BIA, you will need to enter the contact email address for the students Wellbeing Officer / Team in the field below - this will drive all comms to the students College.  To find their email address go to https://docs.google.com/spreadsheets/d/1oVVZoOUvZMO7jS6dKnLueoIqqQDM5lLyTQKd1-T6Xxs/edit#gid=0

Create Student Wellbeing & Partnership Case

Mentoring agreement

Mentee declaration

By submitting this form you agree that when participating in the Graduate Mentoring Scheme, you will:

  • carefully read through the online mentee training course before making contact with mentor. (This will be sent in the confirmation email if successful.)
  • attend the mentee induction training event unless you have a valid reason for not being able to attend.
  • contribute to the scheme to the best of your ability.
  • behave in a professional and courteous way when interacting with your mentor.
  • keep in regular contact with your mentor during the scheme from July 2016 to December 2016 and inform Careers Network of any problems.
  • provide feedback on your experience of the scheme.

Confidentiality agreement

During the mentoring relationship we aim to have an open and honest environment. We trust that you will treat all information shared by your mentee as confidential and that you will contact us if you feel you are experiencing any difficulties.

"I agree to keep the specifics of my discussions with my mentee confidential. I can discuss any concerns I have about my mentoring experience with the Careers Network Mentoring team, who will maintain confidentiality unless a breach of confidentiality is necessary to maintain someone’s personal safety."

Data protection

By submitting this form, you consent to the University of Birmingham processing your data on our systems for the purposes of administering the scheme for which you have registered. This data will be held and processed in accordance with the Data Protection Act 1998 and will not be retained for any longer than is necessary. Your data will not be passed to any third party, except where required by law.

We may also use the data you submit on this form to contact you about other Careers Network and University of Birmingham events and activities that we feel may be of interest to you. If you wish for us to contact you in this way, please check the relevant box.*
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