To Request An Appointment Callback Please fill in the PALS Online Referral Form

PALS ONLINE REFERRAL FORM

PALS ARE CURRENTLY CLOSED FOR THE SUMMER

We reopen on the 1st September, and will be able to accept new referrals then.

Please do not complete this form until the 1st September.

Thanks,

Clinton.

WAITING LIST INFORMATION

(LAST UPDATED 14/6/2022)

Educational and Attainment Testing waiting list

Mid September 2022

Age 7 years and up (including adults).

Comprehensive Assessment Waiting List

(Under 18 year olds only)

Phase 1: October 2022

IF YOU ARE LOOKING TO COMMENCE A COMPREHENSIVE ASSESSMENT (Phase 1), PLEASE COMPLETE THIS FORM NO SOONER THAN OCTOBER 2022 TO START THE PROCESS. WE CAN NOT CURRENTLY ACCEPT REFFERALS COMPLETED PRIOR TO OCTOBER.

Phase 2 (where phase 1 already completed): September 2022

6 years is the youngest for all other emotional/behavioural queries, however often 7 years and up is a better age for assessment.

Autism (ASD) assessments can be completed from the age of 3 years and up, but will be limitted to only an ASD assessment when the child is younger than 6 years.

Please note that we are closed for July and August,

For primary and secondary school students, phase 1 can only commence in October 2022, to allow time for techers to familiarise themselves with their students after the summer break.

Phase 2 appointments are now available from mid September onwards (where phase 1 has already been completed)

Phase 1

New referrals for comprehensive assessments will be contacted within a few days of completion of this form to initiate Phase 1. However, phase 1 can now not commence until October 2022, due to the summer break (we need to allow 1 month for students to be back in school in order to allow teachers to score our forms).

For these assessments, an appointment wil not be considerd until completion of the Phase 1 screening phase.

This is a consultation phase only and does not provide a written report.

Phase 2

Phase 2 apointments are currently being offered for Mid September.

Please note that 3 years is the youngest age for Autism queries.

6 years is the youngest for all other emotional/behavioural queries, however often 7 years and up is a better age for assessment.

Phase 3

Where required, a phase 3 appointment is normally scheduled within 4 weeks of the completion of Phase 2.

PALS ASSESSMENT INFORMATION LINKS (Pricing, etc)

Attainment Testing

(Used for DARE appications when a diagnosis of SLD already exists)

Psycho-Educational Assessments

(For learning difficulties, such as Dyslexia)

Comprehensive Assessments

(For diagnosis Emotional & Behavioural difficulties and may also include a Multi-disciplinary ASD assessment where appropriate)

To arrange a callback to discuss your referral, please provide your details below.

Name of child/person who is to be assessed*

Date of Birth of person to be assessed*

Your Name. Please note this form is to be completed by the parent/legal guardian (or self for adult self referrals).*

Preferred callback time, if any. (Monday to Friday, 10am to 6pm)

Full Home Postal Address and Eircode*

What is the main reason for your referral?

If person being assessed is currently in education, what class/year is he/she in?

Which type of assessment do you require (see links on tops of this page for more information regarding each)

Attainment Testing

Psycho-Educational Assessment

Comprehensive Psychological Assessment

Not sure

Do you have any concerns relating to learning difficulties that you would like PALS to assess? If yes, please describe these concerns.

Do you have any concerns relating to emotional, behavioural or social difficulties that you would like PALS to assess? If yes, please describe these concerns.

How long have you had these concerns?

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?

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.

CONSENT (Please enter your name to confirm your consent and agreement) - By submitting this form I give parental/guardian consent to Psychological Assessments & Learning Solutions (PALS) to assess the above named individual. * I understand that this may include an interview with me and my child, and the administration of psychological and psychometric tests. * I have informed all parties who may impact on this consent (e.g. others with parental responsibility rights to your child))* I understand that the psychological report will be sent to me and I have provided details of any other third parties I wish the report to be sent to (e.g. school). * I consent to PALS holding physical records of the assessment for up to 1 year and electronic data for 6 years, after which they will be securely shredded/deleted. * I understand that I have the right to modify and remove this consent at any time.