Student's course details
IMPORTANT - Please provide the FULL course title, including the degree type i.e BA, BSc, MA,
MSc, PhD etc.
Some examples are: coping with anxiety, reducing stress, confidence building, concentration
skills, guidance to create a healthy work/study-life balance etc.
Please give as much detail as possible if you think this student could potentially be a danger
to themselves and/or others
Please note that all mentoring referrals for UMO's mentoring support must be accompanied by a DSA
purchase order (if the student is being funded by the HEI etc.)
IMPORTANT - Referrals submitted without a document that verifies the student's support funding will be
place on hold.
Referrer's contact details
For students completing this form please provide the contact details for your Mental Health Advisor
For HEI staff, please provide details of the person who should be notified when the student's mentoring