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*

Student details

Student's Name*
Is this their preferred name?
This will help us identify the student swiftly
@student.bham.ac.uk
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?*

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 08:30 - 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

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