Single Advice Session - Agreement for Study Abroad and Distance Learners

Thank you for requesting a Wellbeing Service Single Advice Session.

The focus of this session will be to:

Identify current issues that you are experiencing
Offer support, advice and guidance
Formulate a plan of next steps
Explore support, resources & networks available to you

When supporting students at a distance it is essential that safe working guidelines are followed for both student and practitioner. Therefore, we request that you complete, sign and return this form before a session can take place.

First name *
Surname *
Student ID *
Date of birth *
Current study abroad/at distance address *
Current telephone no. *

Please complete details for AT LEAST two of the following people: - Next of kin/significant other - Staff member in study abroad institution or work placement - Medical/GP contact in study abroad area or distance learner's home area
Contact 1
Name *
Relationship to you *
Address *
Telephone no. *
Contact 2
Name *
Job title *
Address *
Telephone no. *
Other (optional)
Name
Job title
Address
Telephone no.
Other (optional)
Name
Relationship to you
Address
Telephone no.
Is there anything you would like us to consider when we book an appointment for you?
I have read and understood the information on the Study Abroad/Distance Learners Support webpage about accessing this service
I understand Wellbeing Services are unable to offer a crisis or urgent response service to students abroad or at distance. I recognise that support offered during and after the session will be limited by nature of being remote.
If there are significant concerns about my safety, I understand the practitioner may contact the people listed here and/or other relevant professional or university services. I understand any information would be shared on a need to know basis.
I will complete, sign and return this agreement to Wellbeing Services.
I understand Wellbeing Services will aim to offer me an appointment within 2 weeks of returning this form. However I acknowledge that this period may be longer during times of high service demand and University vacations.
Where it is agreed that a session will be conducted by email further guidance on this process will be sent to me.
Where it is agreed that this session will be conducted by telephone I understand it is my responsibility to check with my service provider about any additional charges for receiving/making international calls.
I am aware that no online service can be 100% secure in terms of privacy & security.
Signed
Date

SAS Request Form

Single Advice Session - Agreement for Study Abroad and Distance Learners