PLEASE CLICK HERE TO REQUEST AN ASSEMENT AND ARRANGE A CALLBACK (PALS operate an online referral system, to arrange an appointment, the parent/guardian is required to complete this form, and we will call you back to discuss the referral in a few days)

WAITING LIST INFORMATION

(UPDATED 15/10/21)

ASD assement waiting list - May/June 2022

All other assessment waiting list - November 2021

Due to unprecedented demand, we have decided to priotize children first, and have made a decison to cease the more comprehensive assessments for adults (that is for emotional, behavioural and social difficulties, inlcuding ASD and ADHD assesments). Our adult service (over 19's) will still provide educational assessments.

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

Name of child/person who is to be assessed*

Full Home Postal Address and Eircode*

Date of Birth*

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?

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 6 to 8 month waiting list for the multi-disciplinary assessments.

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 (Please bring a copy of any relevant previous professional repors 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 (For some phones and browsers, the box below may not appear, this can be resolved be going to the settings button on the top right corner of your browser (3 dots on top of each other) and then clicking on the option there that says "Desktop Site". The consent and captcha options should then show. *

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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