Student Wellbeing Referral Form

This form cannot be used to access crisis support. If you or another person is in immediate danger or there is a risk to life, call 999 immediately (UK). If you experience any difficulties completing the form, please email studentsupport@pace.ac.uk.

Learner Information

Please use this section to provide details of the Learner that you are referring for wellbeing support. If you are self-referring, please add your details here.

Referral Type

StudentHidden and set as default following update in May 2026.

Learner First Name

Learner Last Name

Learner Email Address

Learner Date of Birth

Learner Course Type

Learner Course

Please start typing to narrow the course options to select the course.

Wellbeing Concern

Please provide details of the wellbeing concern.

New or existing concern

New ConcernHidden and set as default following update in May 2026.

Type of wellbeing concern

You/the learner requires wellbeing supportYou/the learner requires disability/accessibility supportYou have noted that the learner is not engaging with their studies and are concerned about progressionNone of the above (please provide further information below)

Type of wellbeing concern further information

Please provide details of the wellbeing concern, including any actions already taken

Is the Learner aware that you are making this wellbeing referral?

YesNoUnsure - Please provide additional details below

Please provide further information

i.e. I have tried to call the student and they have not answered

Unsure Additional Details

Please add any other information that you feel is relevant to this wellbeing referral

Your Details

Please provide your details below. If you are completing a self-referral, please provide your full name and select Learner from the available options.

Full Name

Email Address

Confirm Email Address

Please type your email address again to make sure they match to verify.

Email Match Hidden

Please check your email addresses entered, they must match.

Other Role Information