Self Referral Form

Self-referral Form for Students with Specific Learning Difficulties or Disabilities


Male Female


Phone number:


Current Student Prospective

Programme of study:

Disability (please tick):
Specific Learning Difficulty
Blind/Visually Impaired
Deaf/Hard of Hearing
Mobility Difficulty/Wheelchair User
Social and Communication Difficulties/Asperger Syndrome
Mental Health Difficulty: for example depression, anxiety
Unseen Disability or Chronic Health Problem

Additional Information:

Please click on the Submit button to send the form by email.

Alternatively, please click on Print and post to:

Additional Learning Support,
Fourth Floor, University Library
University of Surrey ,
Guildford ,
Surrey GU2 7XH

Additional Learning Support
4th Floor
University Library
University of Surrey

Tel: 01483 689609

Page Owner: lbx063
Page Created: Tuesday 31 August 2010 15:09:39 by lbx063
Last Modified: Wednesday 28 May 2014 15:11:02 by cg0016
Expiry Date: Wednesday 30 November 2011 15:07:59
Assembly date: Thu Aug 21 17:37:41 BST 2014
Content ID: 35585
Revision: 5
Community: 1308