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Health, Wellbeing and Inclusion Request Form

Privacy/Collection Statement

Your privacy is important to us. Our Health, Wellbeing and Inclusion team respects the privacy of your personal information. The Health, Wellbeing and Inclusion division collects personal information about you and your needs, so we can ensure we care for you in the best possible way.

Privacy Legislation protects personal information that we collect and hold. When you see one of our team, we are required to maintain notes of sessions, treatment and/or intervention plans. Your agreement to privacy and confidentiality remains within the division, not with the individual team member you may see. This means that our teams can work collaboratively as a one service, to provide you with the best service and support.

We will only disclose information to third parties within the University and external/outside of the University, outside of the Health, Wellbeing, and Inclusion Division under very specific circumstances. For example; we may be required by law to provide information to state authorities, or where our duty of care requires us to disclose when we are concerned you are at risk of harm to yourself, others, or children”

Please read our full privacy statement. (Please note, this opens in a new window)

We will go through the privacy statement and confidentiality with you when we meet with you.

Declaration *
Personal details
(this must be your La Trobe student email address eg: J.Bloggs@students.latrobe.edu.au)
Date of Birth *
Are you currently linked in with our services?
You will then be asked some questions which will ensure the right person contacts you as soon as we can.
**Disclaimer: we acknowledge that there may be several issues for which you are needing support – please choose the -most- pressing issue, and we will gather more details when we speak with you in person
I have concerns about keeping myself safe Please select the most applicable to you
If possible, I would like to speak to a
(General, or COVID-19 specific)
I have concerns about my capacity to keep myself safe Please select the most applicable to you

To provide a report to the university, please complete the Safer Community Reporting form.

(recent/historic)

To provide a report to the university, please complete the Safer Community Reporting form.

Do you currently have concerns about keeping yourself safe
I would like to talk to the Men’s Health and Wellbeing Counsellor
Do you currently have concerns about keeping yourself safe
I would like to talk to the LGBTIQA+ Health and Wellbeing Counsellor (Bundoora)
Do you currently have concerns about keeping yourself safe
I would like to talk to the LGBTIQA+ Health and Wellbeing Counsellor (Regional)
Do you currently have concerns about keeping yourself safe
I would like to talk to the Indigenous Health and Wellbeing Counsellor
I am an Indigenous Australian and would like support to meet my learning needs better
I am a person living with disability, mental health or ongoing medical condition and would like assistance with obtaining reasonable
I identify as Autistic, have ADHD, Dyslexia and/or another minority neurotype with neurodiversity support needs
I am the carer of a person living with disability or who is frail/aged
I would like assistance with physical access concerns
I would like to know more about Assistive Technology options
I would like support or assistance on an inclusion matter
I would like to speak with a financial counsellor
COVID Vaccination Status * To access Health and Wellbeing services face-to-face you are required to be double vaccinated and may need to show proof of COVID vaccination on entry.


Validation