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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