Wellbeing Mentoring Referral Form
UMO Wellbeing Programme
Email address *
Full name *
Date of birth *
Term-time address *
Mobile *
Preferred method of contact by mentor *
Course title *
Year of study *
Reasons for requesting mentoring *
Session availability
Most mentors are available on-site during office hours and a few mentors are available for evening and weekend sessions. UMO's Wellbeing mentoring is 1:1 support, and students are required to attend regular one hour session slots.
Please provide your weekly availability *
Other support being accessed, if any *
Disabled Student's Allowance (DSA)
Eligible students can apply for DSAs to cover some of the extra costs faced because of a mental health problem, long term illness or any other disability. Allowances are non-repayable and allocated in addition to any other student finance.
Are you aware of DSA support for mentoring? *
Are you eligible for DSA?
Are you in contact with Goldsmiths' Disability Service staff? *
Consent to disclose mentoring progression
Please confirm your consent our mentor to use when reporting back to Goldsmiths' Wellbeing team
Level of disclosure *
Do you have a history of violence or aggression *
Have you previously received support from UMO? *
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