PALS ARE CURRENTLY CLOSED FOR THE SCHOOL HOLIDAYS

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

WE WILL BE UNABLE TO GET BACK TO YOU REGARDING YOUR REFERRAL UNTIL SEPTEMBER

WAITING LIST INFORMATION

(UPDATED 25/6/21)

PALS Are closed for the month of July and August, any referrals received during this period will not be responded to until September.

ASD assement waiting list - January 2022

All other assessment waiting list - October 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*

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.

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*

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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