Is this a first time appointment Yes No

If you have used the service before, who is your adviser? Don't know/ can't remember Shona Robertson Julie Summers Saima Bashir Claire Rattray

Forename

Surname

Address line 1

Address line 2

Address line 3

Town/City

Postcode

Telephone number

Mobile number

email address

SAAS/SLC Number: (if applicable)

Date of birth

College or School

Course(s) or Course Title

Student Registration Number

Please check all that apply to you:

Undergraduate

Postgraduate(R)

Postgraduate (T)

Full Time Course

Part Time Course

DACE

Year of Study

Repeating the year?

Please check all that apply to you:

A specific learning difficulty such as dyslexia, dyspraxia or AD(H)D

A social/communication impairment such as Asperger's syndrome/other autistic spectrum disorder

A physical impairment or mobility issues, such as difficulty using arms or using a wheelchair or crutches

Deaf or a hearing impairment

A long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy

A mental health condition, such as depression, schizophrenia or anxiety disorder

Blind or a serious visual impairment uncorrected by glasses

A disability, impairment or medical condition that is not listed above

Two or more of the above conditions

Not known - seeking dyslexia screening/dyslexia query

Please indicate any accessibility requirements you have for the interview (e.g. accessible interview room, BSL interpreter, large print forms etc)

If you would prefer to be emailed tick here

You will need to bring evidence of your condition to a first appointment. If this will be a problem, this can be discussed when we contact you.