Request an Assessment

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

COVID NOTICE, IMPORTANT, PLEASE READ:

During current Level 5 Restrictions PALS can only accept appointments for assessments that the client feels to be URGENT AND ESSENTIAL. If you feel the assessment you are requesting is urgent and essential, please state this in your query below. If you do not feel it to be urgent and essential, please can you contact us again at a time when existing Level 5 restrictions are lifted and it is safer to travel. We are currently not booking nonessential appointments due to the uncertainty as to when it will be possible to resume this service. Many thanks.

Full Home Postal Address and Eircode*

Who is the Assessment for? *

Name of person to be assessed*

Date of Birth*

What Assessment are you Interested In? *

Reason for assessment/Outline of concerns*

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)*

Please Upload and files/reports that you feel are relevant to the assessment

Full address of third parties I wish report to be sent to (e.g. School): State self only if you only wish report to be sent to yourself, and in this case, 2 reports will be issued to you. *

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.