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Student Psychological Services
Registration Form

The following form takes a few minutes to complete and provides us with information to better understand your concerns. This information is confidential and will not be released without your permission. Please answer the questions thoroughly.

Fields marked by an * must be completed.  

 
YOUR DETAILS
*First name:
*Last name:
*Student Number:
Please note that we cannot accept your registration form if you do not have a valid student number and password
*Date of Birth :
*Gender :
CONTACT INFORMATION
*Address during term time 
House number or name :
Street :
Town :
Postcode :
Country :
If your term address and home address is the same,
click here to copy.  
*Home Address 
House number or name :
Street :
Town :
Postcode :
Country :
Enter your preferred email to be used for all appointment correspondence.
Please enter again to verify
*Preferred E-mail
If you have a UCL email, please enter here
UCL E-mail
*Main Contact telephone number
*If we have to contact you for some reason, which method would you prefer?

[Please note that all appointments will be notified by email, regardless of your above selection.]
*REFERRED BY:
If other, please specify :
*FEE STATUS:
*DISABILITY:
If Yes, then please specify below:
If other, please specify :
ETHNIC ORIGIN
Asian or Asian British
If other, please specify :
Black or Black British
If other, please specify :
Mixed Race
If other, please specify :
White
If other, please specify :
Other Ethnicity
If other, please specify :
Information Declined
STUDIES AT UCL
*Course Title :
Year Course Started at UCL :
*Faculty:
*Status:
*Year:
*Full-time student:
HEALTH HISTORY
*Have you had prior counselling/psychotherapy/psychiatric treatment?

If possible, please give details of treatment
(and diagnosis, if you were given one)

Prior and current significant illness, surgery or allergies:
*Current GP:
Name of GP :
If other than UCL GP, please enter practice details
 
Practice Name :
Street :
Town :
Postcode :
Country :
Medications (dose/frequency):
(Include herbal remedies/nutritional supplements in your list)
Currently

In the past
*Have you ever been hospitalised for any reason?
If YES, please give details
EDUCATION
Previous College(s)/Universities:
EMPLOYMENT STATUS
*Are you currently employed?
if yes, please give occupation:
Number of hours you work per week:
FINANCIAL SUPPORT
*Who supports you financially?
*Do you have medical health insurance?
If yes, please enter the name of
your Insurance Company?
RELATIONSHIP BACKGROUND
*Your Relationship Status:
If married or partnered, how long?
Partner's First name:
Age: 
Occupation:
*Are your parents:
If divorced, separated or deceased, when?
Your age(s) then?
Does your father have a new partner?
Does your mother have a new partner?
*PLEASE LIST YOUR FAMILY MEMBERS:
Family memberAgeCity/CountryOccupationIf a relative is deceased, please give their age, and the date and cause of death

PLEASE COMPLETE THE FOLLOWING SECTIONS REGARDING YOUR REASONS FOR SEEKING AN APPOINTMENT WITH US
*(Please check all concerns that are troubling you):
*Do you ever have suicidal and/or homicidal thoughts?
If YES, please describe:
Reason for Appointment (Please describe your difficulties and specify approximately how long these problems have been affecting you):
How have you managed your problems in the past?
*What are you hoping to gain from seeing one of our therapists?