Student Services Referral Form

Please note:

Student Services adheres to the Student Privacy at QUT procedure when collecting, using and disclosing student information. Details of QUT's practices regarding student information and privacy are available from QUT's privacy webpage.

The information on this form is collected for the primary purpose of assessing and responding to the request for support or welfare check.

Information provided will be reviewed during business hours.

If you believe the student is unsafe and requires immediate assistance, please call emergency services first on 000, and then call QUT security on +61 7 3138 8888.

Questions marked with an * are mandatory.

Has the student provided consent for you to make this referral? (required)

Yes

Your details

Your contact details (QUT may contact you for further information): (required)

First Name

Last Name

Contact Details (required)

Phone

Mobile

Student's details

Is the student under 18 years of age?

Yes

Unsure

Is the student currently enrolled at QUT?

Yes

Unsure

Student ID

Details of the student you are concerned about (if known)

First Name

Last Name

Student’s preferred name

Student's address

Address

City

State

Country

Postcode

Student's contacts

Phone

Mobile

Overview of presenting issue

Summary of presenting issue (required)

Have you advised the student to contact Student Services for an appointment? (required)

Yes

Purpose of referral (please tick all that apply)

Consultation to discuss concerns / advice on supporting the student

Student Services welfare check

Appointment for student

Other

End of Student Services Referral Form – Submit Now