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This is a referral form for the LIPA Student Wellbeing & Disability Service and should be completed by the person seeking support or the referrer.

You will need to complete all sections within this form where possible.

Once you have completed the referral form, please click the submit button at the end. We will use the information you provide to offer you advice and support.

Please note, the LIPA Student Wellbeing & Disability Service is not a crisis service. If you are concerned about your mental health or feel that you cannot keep yourself safe, please contact the following services for urgent support:

  • If there is an immediate risk to you or others, or someone's life is in danger, call 999 and don't delay.
  • Access your nearest Accident and Emergency (A&E) department where a mental health professional will be able to assess you and give you the right help. The nearest A&E to LIPA is at the Liverpool Royal Hospital.
  • If you feel you can keep yourself safe until an appointment, contact your GP and request an urgent mental health appointment.
  • If your GP is closed, you can call 111 if you are in need of urgent medical help or advice but it’s not an emergency or life-threatening situation. You can also call 111 if you’re not sure which NHS service you need.
  • For urgent mental health support in Liverpool, please ring the Mersey Care Mental Health Crisis Team on 0151 296 7200 or by freephone 0800 145 6570, available 24/7.
  • Call the LIPA 24/7 Support Line on 0800 028 3766
  • Call the Samaritans 24/7 on 116 123

Useful links:

Key Information

Are you referring yourself, or somebody else?

Full name, as given at enrolment

Please enter your student number. This can be found on your LIPA Student ID card, below the barcode

Please tell us your LIPA email address

Please tell us the students LIPA email address

Please tell us your personal email address

Please tell us your contact number

Please tell us what you're studying at LIPA

Please tell us what the student is studying at LIPA

If you have an assigned Learning Guidance Tutor, please tell us their name

Please tell us if you have been diagnosed with any condition relating to your mental health, physical health, or a disability

If you answered 'Yes' to the previous question, please provide details of which GP surgery you are registered at

Trusted/Emergency Contact

Do we have the correct details for your Trusted Contact (Emergency)?

What is the relationship between you and your trusted contact? (e.g. parent; relative; friend)

How can we get in touch with your trusted contact (Telephone number/Email Address)

Would a translator be needed to communicate with your trusted contact?

If you told us we need a translator to communicate with your Trusted Contact, please tell us which language(s) we'll need to translate

How We Can Help You

Please select any areas of concern you feel you need support with at the moment

Please share any further information about your identified areas of concern to help us provide you with the right support. Include any details that are relevant to your reasons for referral

Which of the following forms of support do you think you would benefit from? (Please select all that apply)

Are you, or have you experienced any thoughts of self-harm or suicide?

If you answered yes to the previous question, please tell us how long you have felt this way

Please use this space to let us know of any further information you think might help us to support you (e.g. accessibility or communication needs)

External Support

Are you accessing or receiving support from any external services at the moment? (e.g. private counselling, social worker, mental health professional)

If you answered 'Yes' to the previous question, please provide details of the external services you are accessing

Do you have any of the following support systems in your life at the moment?
Areas of Concern

It would help us to have some background information about the issue or concern you have about the student. Please select all relevant issue(s)

Please use this space to share any further information about the areas of concern you have selected to help us provide the student with the right support

If you have answered 'Yes' to the above question, please provide further information here

Identifying How We Can Help

Which of the following forms of support do you think the student would benefit from? (Select all that apply)

Do you have any concerns about the students' attendance, or have they missed any important submission dates?

If you're raising concerns about a student's attendance or missed submissions, when did you last see the student, and could they be classed as "Missing" under the Missing Students Procedure (Appendix E in the LIPA Wellbeing Policy)?

Data Consent

Handling your information and what happens next

We know that confidentiality is important and we are committed to creating an environment where students and staff are comfortable in seeking support. Disability and Wellbeing services will hold and process data in line with our Data Protection Policy.

Upon receipt of your referral form, a member of the team will review this and make contact with you within a timeframe based on assessment of priority. If your situation changes and becomes more urgent, please get in touch with us by phone or email, or follow the guidance on the LIPA Crisis Support Page.

We welcome your feedback!

If there is anything you'd like to share about the quality /layout of this form, please send us an email to wellbeing.disability@lipa.ac.uk

Student Wellbeing and Disability Team

Mon-Fri 09:00-17:00 (term time)

T: 0151 330 3013

E: wellbing.disability@lipa.ac.uk

Handling your information and what happens next

We know that confidentiality is important and we are committed to creating an environment where students and staff are comfortable in seeking support. Disability and Wellbeing services will hold and process data in line with our Data Protection Policy.

Upon receipt of your referral form, a member of the team will review this and make contact with the student and/or you within a timeframe based on assessment of priority. If the situation with the student changes and becomes more urgent, please get in touch with us by phone or email, or follow the guidance on the LIPA Crisis Support Page.

We welcome your feedback!

If there is anything you'd like to share about the quality /layout of this form, please send us an email to wellbeing.disability@lipa.ac.uk

Student Wellbeing and Disability Team

Mon-Fri 09:00-17:00 (term time)

T: 0151 330 3013

E: wellbing.disability@lipa.ac.uk