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Non-DSA Needs Assessment form

Referrer details

University/college:
University/college 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

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

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:

eight eight eight

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

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01204 534 311

Barry Bennett Ltd
Bennett House, Viking Street
Bolton BL3 2RR