Ayrshire College Mental Health Referral

Company

This field is for validation purposes and should be left unchanged.

Who is referring?*

Has student consented to Ayrshire College referring to The Talking Rooms?

Please seek consent from the student before attempting to submit a referral.

Student Name*

Student Phone Number*

Student Email Address*

Date of Brith*

Student Reference Number*

Student's Campus*

Have you previously accessed any type of treatment or support for your mental and emotional wellbeing (from college Student Experience Services or other mental health services)?*

When did you access this treatment?*

What type of treatment or service did you previously access?*

Are you currently on any prescribed medication?*

What medication are you currently taking?*

Is there anything you would like to add?

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Ayrshire College Referral