Counselling Form - DOC

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Counselling Form - DOC Powered By Docstoc
					                                                                                                Office Use Only
                                                                          No: ……………..

                                                                          Mentor: …….………………………..…

                                                                          Appointment: …………………………..



Mentoring Form
                                                      Date:

First Name                                            Surname:                           Sex:   M/F

Student ID number: ______________________________

Term time address:                                    Date of Birth:

                                                      Home address




Tel Number:                                           Tel Number:

Email (PLEASE PRINT CLEARLY) _____________________________________

Name and Address of GP/Psychiatrist/Other support worker:




Telephone Number:


Site:    Harrow/ Cavendish/ Regent/ Marylebone School:

Subject:                                              Level: BA/BSc/MA/MSc/Foundation/Diploma/PhD/Other

Year:             ________ Full–time / Part–time

How did you hear about the service?:                  Referred by

Do you receive a Disabled Student Allowance?: Yes/No

Fee status:   Home / EU / International / Refugee

Ethnic origin: __________________________________
_______________________________________________________________________________________________________


I confirm that I have been given a copy of the Code of Practice on
confidentiality and Data Protection and I agree to the terms and
conditions therein.

Please Sign…………………………………………………….Date……………………………
                                                                 Office Use Only
                                               No: ……………..…..

                                               Counsellor: …………………………..…

                                               Appointment: …………………………..

Can you state briefly something about your mental health difficulties?
(There is no obligation to complete this section)