Student Support Referral Form For use during Undergraduate term-time

Student Support Referral Form

For use during Undergraduate term-time

This form enables you to engage with each individual team from the Student Support department.

By selecting yes in the relevant section of this form, you can declare disabilities/conditions to access Disability Support, refer in for mental health support using the Health & Wellbeing section (during term-time), or ask questions about student funding and accommodation. If you select no in a section, that respective team will not receive your responses.

These forms can be accessed and submitted multiple times at any point by enrolled students.

Average completion time: 5-10 minutes

General questions about you

First Name*

Surname*

Preferred name

If different from your registered first name

Student Support department use only

Preferred pronouns

Student Support department use only

Student ID*

e.g. WHI89098909

Student email address*

Please provide your Leeds Conservatoire email (e.g. WHI89098909@leedsconservatoire.ac.uk)

Course pathway*

Select

Year of study*

Select

Disability Support at Leeds Conservatoire

Do you want to declare a disability, neurodiversity, mental health condition and/or long-term health condition to the conservatoire?*

To request reasonable adjustments, you must answer yes and complete the following section.

Information declared in this section will not be shared directly with other Student Support teams.

If you have already declared your disability and have no new information to share, please select no.

Select

Disabilities/conditions that you have*

Please list the names of any disability or condition that you have here

Details of disabilities/conditions*

This could include how you feel any condition may impact your studies, and/or information you feel relevant staff (such as your course team) should know.

The contents of this answer will be used directly and unedited on any Individual Adjustments Plan (IAP) created for you, which is shared with course staff and will can only be edited at a later date on your request (by emailing disability@leedsconservatoire.ac.uk).

If you have mobility difficulties, are a wheelchair user or have a registered service animal, please clearly detail this information below.

Did you have exam access arrangements in place in school/college?*

Only select yes if you had formal adjustments in place in the past

Select

Details of previous adjustments*

Please list any adjustments that were formally in place for you in school or college

Alternative Assessment Arrangements

Although you can submit this form without attaching Supporting Information for your request, you may need to provide some to access adjustments to assessments at the conservatoire. Therefore, please attach any Supporting Information below that show your disclosed conditions or specific requirements, or otherwise, email it to disability@leedsconservatoire.ac.uk as soon as possible after submitting this form. Supporting information could be in the form of a letter from a health professional, a diagnostic assessment, or evidence of exam access arrangements from a school/college.

Drag and drop files here or

Additional Support/Funding Information

Please see the Disability Support SPACE page for more information about additional funding and support, including advice about Disabled Students' Allowance (DSA) which students eligible for UK funding can apply for, information for International students, as well as details about the Skills for Learning service available to support all enrolled Leeds Conservatoire students.

Health and Wellbeing Support for enrolled Leeds Conservatoire students

Do you want to refer into the Health and Wellbeing Team*?*

*The Health and Wellbeing team can support you during term-time with practical, emotional, or mental health-related issues that are affecting your life at the conservatoire.

Information declared in this section will not be shared with the Disability Support Team. To declare a disability, please complete the section above (relevant information can be copied and pasted).

Select

Term-time address*

Phone number*

If international, please use the corresponding +XX number for the country of origin (e.g. +447999999999)

Phone

Doctor's Surgery/GP practice details*

If you have not joined a GP in Leeds, please consider registering with the Leeds Student Medical Practice here.

Have you had previous contact with the Health and Wellbeing Team? And have you accessed any other wellbeing support outside of the conservatoire?

If yes, please give details. If no, leave this box blank.

Are you currently taking any medication?

If yes, please give details. If no, leave this box blank.

Please give a brief description of your current difficulties:*

Tell us about anything that is causing you difficulties at this time. This could include:

Any diagnoses you have
Issues related to your course or studies
Anything to do with your ability to take care of yourself
Relationship struggles
Substance use

We will use this information to find the best support for you.

Are you struggling to engage in meaningful activities?

e.g. exercise, hobbies, socialising

Are you struggling to maintain a regular food intake?

Are you currently or do you have a history of self harming behaviours?*

Select

Are you struggling to engage with the conservatoire or are you considering withdrawing from your course?*

Select

Are you currently experiencing any suicidal thoughts?*

Select

Do you have any accessibility requirements or appointment preferences?

Select all that apply. If you have no accessibility requirements or appointment preferences, please leave this section blank.

Select

Please give details of your accessibility requirements*

We will try to accommodate these requirements where possible.

Do you consider yourself to belong to any of the following groups?

This is not a mandatory question. However, answers will help us identify students who may require additional support under our Access and Participation initiative. Please select all that apply.

Select

It would also be very helpful if you would let us know which minority ethnic group you identify with.

This is not a compulsory question.

Advice for students

We offer a non-urgent service for enrolled students during term-time only. If you answered yes to the questions regarding self-harm or suicidal thoughts we will attempt to see you as quickly as possible. If you feel you need urgent support in the meantime, please consider the following options:

Visit Mindwell Leeds for advice and a comprehensive list of local services
Call Samaritans on 116 123
Text 85258 for support from Shout
Call the non-emergency NHS line on 111
Attend A&E at your local hospital, or contact your GP

If you are in crisis, call the Single Point of Access on 0800 183 1485 (open 24 hours, 7 days a week)

If you have injured yourself or taken an overdose, or if you are in danger of hurting yourself or taking your life, call 999 and ask for an ambulance, or attend A&E.

D/deaf students can text 'DEAF' to 85258 for specialist crisis support from SignHealth.

Funding Team

Do you want to ask the Funding Team any questions about your student funding or finances in general?

This question can be left blank if you do not wish to make contact with the Funding Team.

Select

Please tell us the nature of your query*

Select as many options that are relevant and then please ask any questions in the following text box

Select

Please ask your question about Funding below*

A member of the team will get in touch with you to answer your question, or book you in for an appointment if necessary.

Accommodation Team

Do you want to ask the Accommodation Team any questions about your student living arrangements?

This question can be left blank if you do not wish to make contact with the Accommodation Team.

Select

Please ask your question about Accommodation below

A member of the team will get in touch with you to answer your question, or book you in for an appointment if necessary.

Privacy, Information Sharing & Submission

Please read below, agree to the terms, and submit your referral form.

In order to best support students with any disability, health & wellbeing difficulty, student funding query, and/or accommodation query, we use the data collected from this form in accordance with the Leeds Conservatoire HE Student Privacy Notice. Your records are securely stored for 7 years after you leave the conservatoire, whilst we use anonymised data for statistical analysis.

To provide you with the best service possible, teams within the Student Support department may collaborate with each other through specific and limited information sharing when necessary. In some rare cases, we may share your information with external agencies (such as the NHS), but we'll consult with you beforehand where possible.

Preferred names and pronouns given in this form are used by the Student Support department only, so please ensure that you still make formal declarations to the conservatoire using the Registry team processes available on SPACE.

By submitting this form, you agree to these terms. Please do contact help@leedsconservatoire.ac.uk if you have any additional questions. The data collected through this form can be reviewed at any point unless there is an immediate safety issue.

Send me a copy of my responses

Privacy Notice|Report Abuse