College Student Form

Referral Form for a Psychological Assessment Private, confidential, and without prejudice


Please fill in all fields marked with an *

* Name:
* Date of Birth:
* Address:
* Parent(s) or Guardian(s):
* Telephone number(s):
* Email Address:
* College:
* Year:
* Course:
* College Telephone Number:
* Name of Disability Officer/s:
* Address of Disability Officer/s:
Student Profile:
* Family size:
* Boys:

* Girls:
* Position in family:
* Were there concerns about the your early development (e.g. walking, talking etc.)? If there were, please give details:
* Are there any medical condition/s that may be affecting your academic progress?
If there are, please give details:

Has you been assessed by any of the following?

* Psychologist: YesNo
Date Assessed:
Outcome:

* Physiotherapist: YesNo
Date Assessed:
Outcome:

* Occupational Therapist: YesNo
Date Assessed:
Outcome:

* Speech and Language Therapist: YesNo
Date Assessed:
Outcome:

* Paediatrician: YesNo
Date Assessed:
Outcome:

* Did you have a hearing test? YesNo
Outcome:

* Did you have a sight test? YesNo
Outcome:

* What are your main academic strengths?
* What are your main academic weaknesses?
* What are your main interests and hobbies?
* What are the main academic challenges facing you in college?
* What measures/resources could be put in place to help you overcome these challenges?
Educational Profile
* Did you receive learning support or resource hours in primary school? YesNo
If you did, please answer the following:
Learning Support

Number of years:
In what subject(s):
How often weekly:
Duration of classes:
How many in the group:
Resource teaching support

Number of years:
In what subject(s):
How often weekly:
Duration of classes:
How many in the group:
Did you receive learning support/ resource teaching hours in post-primary school? If you did, please answer the following:
Learning Support

Number of years:
In what subject(s):
How often weekly:
Duration of classes:
How many in the group:
Resource teaching support

Number of years:
In what subject(s):
How often weekly:
Duration of classes:
How many in the group:
* Did you receive any reasonable accommodations (RACE- reader, scribe, waiver in spelling and grammar etc.) when doing the Junior or Leaving Certificate examinations? YesNo

If you did, please give details:

* Are you receiving any support from the Disability Services in the college? YesNo

If you are please give details:

Consent

I consent to a psychological appraisal by Edward Joyce, Psychologist. Note: The information contained in this application form will be used as part of the evaluation process, and will be seen only by Edward Joyce, Psychologist.

* Name of student:
* Date:
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