Your Name. Please note this form is to be completed by the parent/legal guardian (or self for adult self referrals).*
Preferred day/time (if any) to be called (Monday to Saturday, 10am to 6pm)
Full Home Postal Address and Eircode*
Name of child/person who is to be assessed*
Date of Birth of person to be assessed*
If person being assessed is currently in education, what class/year is he/she in?
Please summarise your main overall concerns and the reason/purpose for this assement.*
How long have you had these concerns?
What, if any, learning difficulties are you concerned about?
What, if any, emotional/behavioural difficulties are you concerned about?
What, if any, social difficulties are you concerned about?
Have any supports/interventions been put in place regarding the above concerns? If yes, please describe.
Have teachers expressed any concerns in relation to these difficulties and have the school put any supports/interventions in place?
Do you require a comprehensive multi-disciplinary diagnostic assessment in respect of Autism Spectrum Disorder (ASD)? Please note that we can only assess individuals aged 3 years or above. These assessments may require two appointments, and full details of pricing can be found on the "What do we do" part of this website. Please note there is currently an approximate 9 month waiting list for the multi-disciplinary assessments.
Background Information: (e.g. Position of child in family, were any developmental milestones delayed, existing health concerns, history of eyesight or speech difficulties, family history of disability, previous professional reports (Please bring a copy of any relevant previous professional reports with you to the clinic on assessment day). *
If you wish to give us consent to speak with any other third parties regarding this assessment (e.g. the school, social worker, etc), please provide their details below.
If you wish the report to be sent to anyone other than yourself, please provide their details below, we will need a name and full address please. If you input "Self Only", we will send 2 copies of the report to only you.
How/where did you find out about PALS?
We would appreciate any feedback or suggestions regarding this form, if there is anything you feel could improve this process for others.