Student Wellbeing Service

Disability and Wellbeing Service

Disclosure Form

Please make sure that you have read and understood the Confidentiality Policy before signing this document.

NB. You may revise this Disclosure Form at any point during your studies at LSE.

This form states that you are giving consent to the Disability and Wellbeing Service at LSE to keep and disclose information regarding the nature and existence of a disability, long term medical or mental health condition or Specific Learning Difficulty, such as dyslexia.

Certain information may be disclosed to relevant personnel or departments as stated in the Confidentiality Policy. As endorsed by our Confidentiality Policy, the Disability and Wellbeing Service adheres to responsibilities under the Data Protection Act 1998.

You can decide, as a responsible adult studying at LSE, the amount of detail you wish to be disclosed. For example, you may agree for relevant staff within LSE to know about the existence of a disability, but not details regarding the specific nature of your disability or condition. The intention of any disclosure is to ensure LSE staff understands the disability and how this impacts on a student’s ability to engage with their studies. This way they can look to put support structures in place.

In many cases, members of the School approach the Disability and Wellbeing Service to investigate the existence of a disability or condition. In such cases, information is kept confidentially, as described above, but the support arrangements might change once a disability or condition is diagnosed. Where there is a specific diagnosis and support arrangements identified, the Disability Adviser will produce an LSE Inclusion Plan (IP) which will supersede this disclosure form. For instance, if a student seeks an assessment for a Specific Learning Difficulty, her/his information will be held in accordance with this disclosure until the IP is produced.

Please state what information about your disability you are happy to disclose:

The disability: Yes No

How the disability impacts on engaging with studies: Yes No

The support in place: Yes No

If you would like certain information restricted to the Disability and Wellbeing Service, please provide specific details below.

At times, there may be a number of issues students are dealing with and they can access any of the support services within LSE. It would be helpful for the services to know you are receiving support from other internal services to ensure we are joined in providing support to you. Please indicate below whether you are in receipt of support elsewhere, and if so whether you are happy for us to share information about the support we are giving.

In receipt of support: Yes No

If yes, which service/s:……………………………………………………………………………

Agree to share information between services: Yes No

Please sign below to indicate that:

·  You have read and understood the Confidentiality Policy

·  You understand and agree that the Disability and Wellbeing Service will hold and release information as detailed in this Policy

·  You give permission for the Disability and Wellbeing Service to request further information about your additional support needs from a relevant professional, educational psychologist, previous education provider or funding body, if necessary

·  You give permission for the Disability and Wellbeing Service to share relevant information for the purposes of putting support in place, including funding bodies, external support agencies and LSE staff

·  You give permission for the Disability and Wellbeing Service to update your Student Record to show your disability category and your Disabled Students’ Allowance (DSA) funding status.

Name: ______Student number: ______

Signed: ______Date: ______

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