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Non-DSA Needs Assessment form

The complete end-to-end support service for your non-DSA funded students

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Non-DSA Needs Assessment form

Please complete the form below

Referrer details

Organisation / college / university:
Organisation / college / university address:
Contact name:
Contact email:
Contact telephone:
Purchase order number:
Invoice address and post code:

Please confirm if your student is :
Research Council funded
International student
Degree Apprentice
University Funded
Apprentice

If you have ticked research council funded, please add the research council below:
Please confirm the disabilities you would like us to consider during the assessment:
Asperger’s syndrome/other autistic spectrum disorder
Long standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy
Mental health condition
Specific learning difficulty such as dyslexia, dyspraxia or AD(H)D
Visual Impairment
Hearing Impairment

Other Information

Please confirm which of the following you would like for us to recommend and quote for:
Assistive technology hardware
Assistive technology software
Assistive technology training
Non-Medical Help support

Student details

Name:
Address:
Telephone number:
Email address:

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Please enter the numbers as digits below (without spaces):

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[email protected]

01204 534 311

Barry Bennett Ltd
Units 47 & 48, Waters Meeting Business Park
Britannia Way
Bolton
BL2 2HH