Student Psychological Services
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
Fields marked by an * must be completed.
Please note that we cannot accept your registration form if you do not have a valid student number and password
*Date of Birth :
Enter your preferred email to be used for all appointment correspondence.
Please enter again to verify
If you have a UCL email, please enter here
*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.]
If Yes, then please specify below:
STUDIES AT UCL
Year Course Started at UCL :
*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:
If other than UCL GP, please enter practice details
(Include herbal remedies/nutritional supplements in your list)
In the past
If YES, please give details
*PLEASE LIST YOUR FAMILY MEMBERS:
PLEASE COMPLETE THE FOLLOWING SECTIONS REGARDING YOUR REASONS FOR SEEKING AN APPOINTMENT WITH US
*(Please check all concerns that are troubling you):
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?