UMO Referral Form: Specialist Services for Students

Support required *

Specialist Mental Health Mentoring

Specialist MH Mentoring (Korean / Mandarin / Cantonese)

Specialist AS Mentoring

Wellbeing Mentoring or Coaching

Diverse Ethnicity Support

Study Tutoring

Other

Student details

Educational details

Course title * Please provide the FULL course title, including the degree type (e.g., BA, BSc, MA, MSc, PhD, etc.)

Support Requirements

Mental health conditions Details of known mental health conditions and / or disabilities

Accessibility needs Please let us know if the student has any accessibility needs e.g. visual impairment, so we can ensure we can accommodate their needs at every stage

Specific support needs Some examples are: coping with anxiety, reducing stress, confidence building, concentration skills, guidance to create a healthy work/study-life balance etc.

Is the student accessing a community mental health team (CMHT) and / or under the care of a psychiatrist?

Yes

Safety concerns Please give as much detail as possible if you think this student could potentially be a danger to themselves and/or others

Session frequency Options: Weekly • Fortnightly (every 2 weeks) • Monthly • Yearly (per academic year)

Funding information

How will the student’s support be funded? *

DSA (Disabled Students’ Allowance)

NHS bursary DSA

HE institutions / Higher education institutions (including Research Councils)

FE Employers / Further education institutions

DAME project / HEI funding

Other

Please provide the student’s DSA customer reference, a purchase order number or alternative funding reference if possible

I confirm that the following document has been submitted to referrals@umo.services to verify funding approval for the student:

SFE DSA letter

NHS bursary DSA letter

HE / FE institution Purchase Order

Other proof of funding

Referrer’s contact details

Please provide details of the person who should be notified when the student’s support begins.

GDPR compliance

As the data controller, please confirm that the student has given you permission to share their personal details with UMO.

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