Registration

Requesting a DSA Needs Assessment takes about 20 minutes.

Details

If you are filling in this form for someone else (e.g. a son/daughter) then please use their details, apart from email/mobile which can be yours (as the main point of contact).

* First Name:

* Last Name:

Date of Birth: DD/MM/YYYY

* Email Address:

* Telephone / Mobile:

* How did you hear about us?

Details:

Home Address

We need your home address for your report, as it is sent to your funding body.

* Address Line 1:

Address Line 2:

Address Line 3:

* Town or City:

County:

* Postcode:

Term Address (optional)

If you have a term address. This can be used in your report for equipment delivery, or accommodation costs.

Address Line 1:

Address Line 2:

Address Line 3:

Town or City:

County:

Postcode:

Notes

How you would prefer your assessment to be carried out?

No Preference Face-to-Face Telephone Video Call, via MS Teams. Other

Please explain the reason(s) for this preference, to help us assist you:

Is there anyone else we can speak to about your assessment, e.g. parent? No Yes

* Their Name:

* Their Contact Details: e.g. Mobile Number and/or Email Address.

* Relationship to You: e.g. Parent, Friend, etc.

Is there anything specific we should bear in mind when communicating with you? e.g. you need larger print size, you prefer email, text messaging, phone calls, time when we can contact you, etc:

Create Password

You can log in with your email address and this password at a later date to review the assessment, upload supporting documents, and access your final report.

Passwords need to be at least 6 characters, but longer passwords are better.

* Password:

* Repeat Password: