Online Booking Form

Full Name:

Gender Please Select ... Male Female Other Prefer not to say

University or College staff or student number:

Contact Address:

May we contact you at this address? Please Select ... Yes No

Email Address (please use your University or College email account):

Mobile / Phone Number: Is it ok to leave messages? Please Select ... Yes No

Preferred Method of Contact: Please Select ... Address Email Phone Text

Date of Birth (eg, 2 Feb 1986):

Age Range: Please Select ... Under 16 16 - 18 19 - 25 25 + Prefer not to say

Have you ever seen a counsellor / psychotherapist, or been referred to a psychologist, psychiatrist or any other mental health professional?: Please Select ... Yes No

If you chose 'Yes' for the previous question, and you saw a professional at the University of Bradford or Bradford College, please give date(s) attended:

If you chose 'Yes' for the previous question, and you saw a professional at another agency, please give details of the agency and the date(s) attended:

Do you consider yourself to have a disability, including chronic illness or mental health difficulties that are covered by the Equality Act?: Please Select ... Yes No

If you chose 'Yes' for the previous question, are you aware of the Disability Service? (this includes the Mental Health Advisers, and is located in the Learning Mall, Student Central, tel. 01274 233739): Please Select ... Yes No

Please provide the name of your Doctor's (GP) practice:

Please provide the address of your Doctor's (GP) practice:

Please provide the telephone number of your Doctor's (GP) practice:

Please provide the name(s) of any medication you are taking:

UK, EU or International: Please Select ... UK EU International

University or College Staff: Please Select ... University Staff College Staff

Full Time or Part Time: Please Select ... Full Time Part Time

Department / School:

Staff Type: Please Select ... Academic Academic Related Admin Ancillary Other

If you chose 'Other' for Staff Type, please complete this field:

UK, EU or International: Please Select ... UK EU International

University or College Student: Please Select ... University Student College Student

Student Type: Please Select ... Undergraduate Postgraduate Further Education Other

Full Course Title:

Year of Study: Please Select ... 1 2 3 4

Full Time or Part Time: Please Select ... Full Time Part Time

Please select ALL the times you CAN attend an appointment

Is there anything else you would like to tell us at this stage about this appointment request?

How did you find out about the Counselling Service?:
Please Select ... Chaplaincy Colleague Department Disability Service Friend GP Health Centre Hub Human Resources International Office Leaflet / Poster Occupational Health Student Union Tutor Website Other

If you chose 'Other', please say where you found out about the Counselling Service:

Have you used this service before?:
Please Select ... Yes No

In accordance with the Data Protection Act (1998) your permission is required for the collection and retention of any personal data. Information kept in the Counselling Service consists of personal details as completed above, plus a record of appointments, including short notes. Written notes are kept in a secure place and destroyed after a period of 3 years.
Please Select ... I consent to the collection and retention of this data I do not consent to the collection and retention of this data

Please note: as this form is no more "secure" than emails, if you are concerned about the possibility that this information may be seen by a third party over the internet, do not click the submit button - instead contact the Counselling Service Administrator by phone on 01274 235750 or in person at the Counselling Service in Student Central.