U-COPE Referral Form

Inclusion criteria;

Currently registered as a student studying at the following universities;

University of Liverpool (UOL)

Liverpool John Moores (LJMU)

Hope University

Liverpool School of Tropical Medicine (LSTM)

University of Liverpool International College (UoLIC)

Liverpool Institute for Performing Arts (LIPA)

Recent (within the last year) self harming behaviour. May be self-reported
Self-harm refers to an intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act, and is an expression of emotional distress NICE 2004

Exclusion Criteria:

Students Information

First Name *

Middle Name

Surname *

Date of Birth *

Date format: DD/MM/YYYY

Ethnicity *

If you are aware of any former or alternative names for this student please list them here

Students Contact Details

House Number *

Street Name *

Address Line Two

City *

Post Code *

Telephone Daytime *

Telephone Evening

Email Address *

We will contact the student via email so please have the email account that they check and are happy for us to use

Students GP Details

GP Name *

GP Practice & Address *

Details of the referral

Has the student self-harmed in the last 12 months? (This is part of our inclusion criteria) *

No
Yes

What are the presenting symptoms of the student? *

Is there any other information you like to share with the U-COPE team (e.g. accessibility issues, communication preferences, etc.)?

Student ID no:

University Services Supporting student currently

Email address of person making this referral? *

Referrer details (name, role, workplace)* *

Recaptcha