EmailMe Form - Health and Disability Questionnaire

Health and Disability Questionnaire

• You are strongly advised to complete this questionnaire to ensure we provide you with the maximum amount of informed assistance’

• Even if you do not have a health condition or disability it is vital you complete the questionnaire before starting your course.

• The questionnaire is confidential and will not in any way affect your application.

• Only specific Student Services staff will see the questionnaires. Responses will be stored electronically, and deleted once you complete your course. Information will only be passed on to other parties with your consent.
‘Why is it important to complete this form?’

• The more information we receive, the better we are able to cater for the specific needs of our students and we want to provide support and information where it is needed.

• Information can also help us respond correctly to emergencies if and when they occur.

• Your information can help us put in place arrangements so you are not unfairly disadvantaged by a disability or medical condition.

• The Conservatoire provides comprehensive support for students’ specific needs; we cannot be expected to provide support in situations where we remain unaware of your particular needs.

• You must tell us, by law, if you condition is likely to affect the health and safety of yourself or others.

Thank you for your assistance and time.

Name *
First Last
Email *
Course *
Please indicate which UCAS disability code applies to you. *
A: No Disability
B: You have a social/communication impairment such as Asperger's sydrome or another autistic spectrum disorder
C: You are blind or have a visual impairment not corrected by glasses
D: You are deaf or have a serious hearing impairment
E: You have a long standing illness or health condition such as diabetes, epilepsy, sickle cell, a heart condition, cancer or HIV
F: You have a mental health condition, such as depression, anxiety, bi-polar affective disorder or schizophrenia
G: You have a specific learning difficulty such as dyslexia, dyspraxia or ADHD (please specify below)
H: You have physical impairment or mobility issues, such as difficulty using your arms, walking short distances or you use a wheelchair
I: You have a disability, impairment or medical condition that is not listed here (Please specify)
J: You have a condition that covers two of the above categories (Please specify)
If you have been asked to specify a condition(s) please do so below:
Mental Health Section: Have you ever been diagnosed with (or suspect you have) a mental health difficulty? (e.g. depression etc)
No
Yes
If yes, what was the diagnosis?
Is the condition still an issue for you?
N/A
Yes
No
Would you like to be put in touch with the counselling service at Trinity Laban?
No
Yes
if you require more information about counselling follow this link: http://www.trinitylaban.ac.uk/student-experience/student-support/counselling-support
Are you in receipt of, or have you applied for, Disabled Student Allowance?
N/A
Yes
No

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