Wellbeing Programme

*Student Name:

*Email:

*Phone Number:

*Preferred method of contact:
Phone
Email

*Student ID number:

1) Who is completing this referral?
Student (self-referral).
UoH Student Wellbeing.
Students’ Union.
ResLife.
Accessibility Team.
Academic / School staff.
Other.

If other, please specify

2) What would you like help with?
Tick any that apply.
Becoming more active.
Feeling more confident attending an activity.
Meeting other students / making social connections.
Finding an activity I would enjoy.
Returning to activity after a break.
Trying something new.
Getting started with Active Students.
Something else.

If something else, please tell us

Anything else you would like us to know

5) What would you like to get from your first activity experience?
Something fun.
Something relaxed / low pressure.
A chance to meet people.
Something beginner-friendly.
A lower-noise / lower-stimulation environment.
A social or team-based activity.
An individual activity.
I am happy for an Activator to recommend something.

Specific days/times that work particularly well

Specific days/times that are not suitable

7) Accessibility and additional requirements
Please only provide information that is relevant to making participation comfortable and accessible.

Accessibility / adjustment information

Anything to know before the first conversation with an Activator

8) Current Confidence

How confident would you feel attending an activity on your own, without an Activator? Select one option.
0 1 2 3 4 5
0 = Not at all confident, 5 = Very confident

How confident would you feel walking into an activity where you don’t know anyone? Select one option.
0 1 2 3 4 5
0 = Not at all confident, 5 = Very confident

How confident would you feel talking to other students at an activity? Select one option.
0 1 2 3 4 5
0 = Not at all confident, 5 = Very confident

9) Consent and expectations
Please tick the box to confirm that you understand the purpose of Active Wellbeing.
I understand that Active Wellbeing is designed to help me access and participate in Active Students activities. It is not a counselling or mental health support service. I understand that an Activator provides practical encouragement and support to help me attend an activity and is not a counsellor or mental health professional. I understand that if Active Wellbeing is not the most appropriate service for my needs, I may be signposted or referred to another university support service.

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

Self-Referral Form

Are you interested in...