Wellbeing Intervention Self- Referral Form

Name *

First

Last

Form *

Please tick the relevant boxes that you would like support with:

• Anger
• Anxiety
• Attendance
• Behaviour
• Bereavement/ Death
• Confidence
• Coping Skills
• Exam Pressure
• High number of detentions/ isolations
• Medical Issues
• Mental Health Issues
• Resilience
• Self Esteem
• Other

Briefly explain how you would benefit from accessing some wellbeing support?

Please note: If a safeguarding concern is raised then this information will have to be shared with Mr Jones and the safeguarding team. We will support you through this process. Forms are only be processed during school hours. If you have any concerns outside of these hours, please contact your GP or call 111. *

• I confirm I have read and understand the above statement

Submit