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Ayrshire College Referral
"
*
" indicates required fields
1
Intro
2
Student Details
3
Session
4
History
5
Details
6
Submit
Who is referring?
*
John
Sylvia
Terry
Wendy
Michelle
Alison
Moira
Kari-Lee
Sharon
Has student consented to Ayrshire College referring to The Talking Rooms?
No
Yes
Please seek consent from the student before attempting to submit a referral.
Student Name
*
Title
Miss
Mr
Mrs
Ms
Prefix
First
Last
Student Phone Number
*
Student Email Address
*
Date of Brith
*
DD slash MM slash YYYY
Student Reference Number
*
Student's Campus
*
Kilmarnock
Ayr
Kilwinning/Nethermains/Irvine
What's your preferred method of contact?
*
Ayrshire College email address
Call to phone number provided
When would be a good time for your session?
*
Monday Morning
Tuesday Morning
Wednesday Morning
Thursday Morning
Friday Morning
Saturday Morning
Monday Afternoon
Tuesday Afternoon
Wednesday Afternoon
Thursday Afternoon
Friday Afternoon
Saturday Afternoon
Monday Evening
Tuesday Evening
Wednesday Evening
Thursday Evening
Friday Evening
Saturday Evening
Select as many as you wish
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)?
*
No
Yes
When did you access this treatment?
*
Day
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Year
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What type of treatment or service did you previously access?
*
Are you currently on any prescribed medication?
*
No
Yes
What medication are you currently taking?
*
What are the main issues/area of difficulties you are facing?
*
Abuse
Addiction
Anger
Anxiety & Panic
Bereavement
Chronic Pain
Eating Disorders
Family
Grief
Loss
Low Mood
Mild to Moderate Depression
Relationship Issues
Self Esteem/Self Confidence
Self Harm
Sexual Identity
Sleep
Stress
Trauma
Something Else
Please provide an outline of the main problems or symptoms
*
Please give an indication of onset and duration
*
Is there anything you would like to add?
Personal Data Consent
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