INFORMATION ON WATING LIST

Name: PALS
Address: Castletown, Ballina, Co. Tipperary, V94 YC90, IE
Telephone: 067 23923

(UPDATED 10/5/21)

ASD assements - November 2021

All other Assessments - Enf of June 2021

We can no longer proivde adult ASD assessments due to high demand and a need to priotise children first.

Name of person completing this form*

Name of person to be assessed*

Full Home Postal Address and Eircode*

Who is the Assessment for? *

Date of Birth*

If person being assessed in 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?

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.

Background Information: (e.g. Position of child in family, developmental history, existing health concerns, history of eyesight or speech difficulties,family history of disability, previous professional reports (attach copy of reports below)*

(Optional) If you have previous reports in digital format that you feel are relevant for this assessment, you may upload them here.

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.

We would appreciate any feedback or suggestions regarding this form, if there is anything you feel could improve this process for others.

CONSENT*

I Hereby give 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 understand that the psychological report will be sent to me and I provide details below 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.

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