DSA Study Needs Assessment Booking Request Form Please only complete this form if you have successfully applied for the Disabled Students’ Allowance (DSA) and have received confirmation from your funding body that you can book a DSA Study Needs Assessment Name First name Last name Date of birth Gender Disability Category Specific Learning Difficulty eg. Dyslexia, Dyspraxia, AD(H)DMental Health Condition eg. Depression, Anxiety, BipolarAutistic Spectrum ConditionLong Term Health Condition eg. Diabetes, Fatigue, EpilepsyPhysical Impairment / Mobility DifficultiesVisual ImpairmentHearing ImpairmentDisability or medical condition not listed above please select all that are applicable Please provide a brief description of your diagnosis/diagnoses University first choice of university if you are an applicant ID number (if a Brunel Student) Course title Course start date Mode of Study Please select Undergraduate - full time Undergraduate - part time Postgraduate - full time Postgraduate - part time Current year of study (if yet to start put 0) Course length (including placement) Funding body Please select Student Finance England Student Finance Wales Student Finance Northern Ireland NHS NHS Social Work Student Awards Agency Scotland Research Council Other Address Postcode Phone Email Assessment preference First available appointmentRemoteIn person If you would like your assessment conducted remotely, do you have access to a computer that you can use for around 90 minutes whilst the assessment is taking place? YesNoNot applicable if you prefer an in person appointment, please choose not applicable. Which method of remote assessment are you happy with? Video communication platform (Teams or Zoom)TelephoneCombination of video communication and telephoneNot applicable If you prefer an in person appointment, please choose not applicable. Have you previously had a Study Needs Assessment? (if yes, please attach) YesNo Previous Study Needs Assessment Have you received confirmation from your funding body to say that you are eligible to have a Study Needs Assessment? (if yes, please attach) YesNo Please upload your confirmation letter Please attach a copy of the medical evidence / diagnostic report that you submitted with your DSA application Once you click submit, you will receive an email notification to confirm that we have received your request. Thanks for getting in touch. Submit