First Name: Family Name: Date of birth: Email: Mobile: Student No. Postal address: (we will not send any letters to this address without your consent) Programme of Study: Duration of Course: From: To: Undergraduate Masters PhD Level of study General Summer Other Course School Home EU International Fee Status Have you seen a Counsellor or a Mental Health Adviser at LSE before? Yes No If yes, please give details of who you saw and when this was? Are you currently seeing a counsellor or other mental health professional? Yes No Are you registered with a GP? Yes No Please give your GP Name and Address Current Medications: Please read each statement and tick a box to indicate how often you have felt that way over the last week I have felt tense, nervous or anxious I have felt I have someone to turn to for support when needed I have felt unable to concentrate on my studies I have had thoughts of hurting myself’ Talking to people has felt too much for me I have had difficulty getting to sleep or staying asleep I made plans to end my life I have been over-eating or I have used or alcohol to cope with my difficulties Please tell us the difficulties you are having and what kind of help you are seeking?
First Name: Family Name: Date of birth: Email: Mobile: Student No. Postal address: (we will not send any letters to this address without your consent) Programme of Study: Duration of Course: From: To: Level of study Undergraduate Masters PhD General Course Summer School Other Fee Status Home EU International Have you seen a Counsellor or a Mental Health Adviser at LSE before? Yes No If yes, please give details of who you saw and when this was? Are you currently seeing a counsellor or other mental health professional? Yes No Are you registered with a GP? Yes No Please give your GP Name and Address Current Medications: Please read each statement and tick a box to indicate how often you have felt that way over the last week I have felt tense, nervous or anxious I have felt I have someone to turn to for support when needed I have felt unable to concentrate on my studies I have had thoughts of hurting myself’ Talking to people has felt too much for me I have had difficulty getting to sleep or staying asleep I made plans to end my life I have been over-eating or I have used or alcohol to cope with my difficulties Please tell us the difficulties you are having and what kind of help you are seeking?
scs-registration-form.docx