Star Assessments | Assessment Booking Form

Appointment

Centre Location:

Your Details

First name:*

Surname:*

Date of Birth:*
--

Pronouns:*

Which do you identify with:

They, them
She, her
He, him

First line of address:*

Second line of address:

Town/City:

County:

Postcode:*

Landline:*

Mobile:*

Email address*

Needs details

Which of the following disability(ies) have you been approved for an assessment for:
Social / communication disorder (e.g. Aspergers, autism)
Visual impairment
Hearing impairment
Long standing illness or health condition
Mental health condition
Specific learning difficulty such as dyslexia or dyspraxia
Physical impairment or mobility difficulties
Other Disability, impairment or medical condition not listed above

If other, please describe:

Please describe your main study difficulties:

What support have you received in the past? (for example people support, extra time in examinations)

Have you used assistive technology, if so please give details:

Have you had a needs assessment in the last 12 months:*

No Yes

If yes, a copy of the needs assessment report would be useful.

If you have a learning difficulty, e.g. dyslexia we require you to provide an Educational Psychologist's report.

If you have any other condition we will require a copy of your supporting medical evidence.

We require a copy of these documents 24 hours before your assessment. This can be scanned and emailed, posted or uploaded through the student portal. Your login details for this will be provided once your booking has been made.

Funding body information

Who is the funding body?*
Student Finance England (SFE)
Student Finance Wales (SFW)
Scottish Awards Agency (SAAS)
Northern Ireland Education Library Board
Open University
NHS
Other funding body, please specify:

Student CRN number:

Are you happy for us to contact the funding body if needed?:*

Yes No

Course details

University/college Name:*

Course:*

Length of course in years:*

Mode of study?:*

Full time Part time

Level of study?:*

Undergraduate Postgraduate

Are you happy for us to share information with the university disability service if needed?:*

Yes No

Equipment details

What equipment do you currently use for your studies (e.g. computer, tablet, printer, etc)? Please give the age of equipment. If you have a computer, please give the make, model, how much RAM and the processor type, this can be found under ‘system’ in the computer settings.

How would you prefer we contact you?:*
Telephone E-mail

Feedback

Is there anything else that you would like to make your assessor aware of that may be relevant to the assessment meeting? :

Please tell us how you heard about the Star Assessments Assessment Centre:

I agree that my name and purpose of my visit will be shared with the venue staff.