Huron At Western - Wellness Services
1349 Western Rd.
London  Ontario  N6G 1H3


Phone: (519) 438-7224
**NOTE: If you are in crisis, please contact your local crisis services. If you are residing in Canada, contact Reach Out at 1-866-933-2023. International crisis lines can be found at https://www.opencounseling.com/suicide-hotlines **

Thank you for reaching out to your Wellness Services.

Please complete the below information to request support from Wellness Services (including your @uwo.ca email). Wellness Services will respond to your appointment request within 24 business hours.

Self-Referral
Please tell us who you are
* First Name:
Last Name:
Preferred Name:
Date of Birth:
Select Date
Age:
Please tell us how we can contact you
Preferred Language:
Please include the area code with phone number.
You can provide additional details to the phone number provided in the adjacent comments box.
Home/Main Phone:
Permission to Call?
Yes
No
Leave a Message?
Yes
No
Comments:
Email Address:
Address:
:
City:
Province:
Country:
Postal Code:
Hide/ShowWellness Intake Form
Pronouns:
Year of Study:
Faculty:
Program of Study:
Are you a Domestic or International student?
Are you currently residing in Ontario?
Yes
No, I am residing in another province
No, I am residing outside of Canada
What prompted you to book this appointment? (Select all that apply)
Stress and/or anxiety
Low mood and/or depression
Relationships
Academic concerns
Seeking resources
Other
If Other, please specify:
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 provide how we can best support you.
What is your best appointment availability?
E.g.: Monday to Friday between 9:00a.m. to 2:30p.m. (last available appointment)
What is your preferred appointment method?
Video Conference
Phone
The Caskey Gilday Wellness Centre
Attachments
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The information you provide is stored within EMHWare and accessible only to Huron’s Wellness Counsellors and Gender-Based Sexual Violence Advocacy Specialist. Your privacy is protected and will be discussed further with you in your first appointment.