UCL HUMAN RESOURCES DIVISION
OCCUPATIONAL HEALTH SERVICE
STRICTLY CONFIDENTIAL
APPLICATION FOR STAFF OR STAFF-GROUP COUNSELLING
UCL provides a free short-term counselling service for its entire staff. The counselling aims to
provide help and support with emotional, personal, work or stress-related difficulties, and
consultation is offered either individually or for groups with common concerns. All UCL staff
counselling is strictly confidential, and the staff counsellor will not reveal information concerning
your counselling to anyone without your written permission. The only exceptions to this are
circumstances where there is a threat to human life or safety.
Applicant’s Surname:
First/Preferred Name:
Department:
Employment Position
at UCL:
Date of Birth:
First Language
Gender:
(if not English):
Preferred Address &
Post Code for
Correspondence:
Preferred Contact
Telephone Number:
Email Address:
(Please provide only those numbers or addresses on or at which you are prepared to be
contacted)
Page 1 of 2
GP Details
Doctors name:
Surgery:
Address &
Post Code:
Telephone No.:
Main Issues involved (optional):
You may or may not wish at this stage to provide a brief description of why you require
counselling, or may prefer to leave this to the first meeting with the Staff Counsellor.
I hereby request an initial meeting with the Staff Counsellor.
Signature: ___________________________ Date:___________________
PLEASE RETURN THIS FORM TO:
(via internal mail) (via external mail)
Staff Counselling University College London
Occupational Health Service Staff Counselling
th
4 Floor Occupational Health Service
3 Gower Place Gower Street
London WC1
University College London Gower Street London WC1E 6BT Page 2 of 2
Tel: +44 (0)20 7679 2802 Fax: +44 (0)20 7209 0256
www.ucl.ac.uk/hr/occ_health/