Student's details

Student's course details

IMPORTANT - Please provide the FULL course title, including the degree type i.e BA, BSc, MA, MSc, PhD etc.

Support Requirements

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 letter, 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 below. For HEI staff, please provide details of the person who should be notified when the student's mentoring begins.

GDPR Compliance

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