3. Disability information

Disability Type (please tick primary disability):

ADD/ADHD □ Dyslexia/ Significant Literacy Difficulties □ Autistic Spectrum Disorder (including Asperger’s Syndrome) □ Mental Health Condition (Include specific DSM-V and/or ICD-10 name and code below) □ Blind/Vision Impaired □ Neurological Condition (including Brain Injury & Epilepsy) □ DCD-Dyspraxia □ Physical Disability (those with significant mobility difficulties) □ Deaf/Hard of Hearing □ Significant Ongoing Illness □ Dyscalculia/ Significant Numeracy Difficulties □ Speech and Language Communication Disorder □ Please state the specific name of the disability/condition (if relevant) NB: for Mental Health conditions, please provide the DSM-5 and/or ICD-10 name and codes): Please state if there are any other disabilities/conditions:

4. History and detail of the disability/condition Is the Disability:

Congenital Acquired

If acquired, is it:

Permanent Temporary/Expected recovery Fluctuating

If temporary or fluctuating, please provide further details:

The severity of the condition(s) is:

Mild Moderate Severe

Please provide as much information as possible about the impact/severity of the condition on the applicant's daily life/functioning (i.e. social, emotional, physical impact).