Wellness Intake Form
Please provide your @uwo.ca email.
Year of Study
Program of Study
Are you a Domestic or International student?
What prompted you to book this appointment? (Select all that apply)
Stress and/or anxiety
Low mood and/or depression
Are you thinking about or have you recently thought about harming yourself or ending your life?
Do you have any accessibility needs?
If yes, please describe and let us know how we can best accommodate (e.g., meeting in a different space). Note: At this time, the Wellness Centre is not accessible by wheelchair.
What is your best appointment availability?
E.g.: Monday 9-12 or Thursday after 3
Should be Empty: