Get wellbeing support for yourself Do you need help? If so, please complete and submit this form. Please include as much detail as possible to help us respond appropriately.Click the submit button when you are finished. You will need to complete all sections and submit the form in one session. By completing this form you are consenting to being contacted through the email address you supply on this form.Required fields are marked with an asterisk. About you First name * Last name * Student ID number * NTU email address * Phone number * Date of birth * About your concern Please tell us about your current difficulties and how long they have been affecting you (including if there is any current risk of harming yourself). * Please tell us how long have you been experiencing these difficulties? * -- Please Select --A few daysA few weeksA few monthsA few years Impact on your studies How well are you coping with your studies? * From 1 - not at all to 10 - coping very well -- Please Select --1 - Not at all2345678910 - Coping very well Are you thinking of leaving? * Yes No About your wellbeing What steps have you taken to support your own wellbeing? * Have you ever received treatment for a mental health issue? * Yes No If yes, then how long have you been experiencing these difficulties? * -- Please Select --A few daysA month or moreMore than a year What are you hoping to achieve from this referral? * Consent Statement: The information you supply on this form will help us respond to your request, including by phone. We'll treat your personal details with respect and keep them safe, and we'll never sell them to other third parties for commercial use. Please review our privacy statement for more information about how we use your data.