Self-Referral Form

Consent (declaration by student)

  • I give my full consent to take part in the Student Wellbeing Active Students referral scheme with the understanding that I may withdraw at any time without giving a reason.
  • I understand that if there are any concerns that the Wellbeing Activator may have, then they will contact Student Wellbeing for advice and support, and they may refer me back to them for any other support needs that may be identified.
  • I understand that the information I give is confidential and will be anonymised.
  • As a part of our research into the impact of health and fitness on wellbeing, anonymised data will be collected. This Data of yours will be fully anonymous, without any personal identifiable information.
  • I have been informed and understand that I can withdraw my consent for data to be used at any point.

If you have any concerns or difficulties with the program, please feel free to contact and one of our project officers will get in touch to try and resolve any difficulties you may have.