Primary School Form – Completed By Parent/Guardian Referral Form for a Psychological Assessment Private, confidential, and without prejudice Please fill in all fields marked with an * * Childs Name: * Childs Date of Birth: * Address: * Parent(s) or Guardian(s) Name: * Telephone Number(s): * Parent/Guardian Email Address: * School Name: * Class/Year: * School Address: * School Email Address: * Name of Principal: * School Telephone Number: * Family size: * Number of Boys: * Number of Girls: * Position in family: * Has your child attended preschool? YesNo School Name: Any other National School Attended: I he/she has, please give details: * Has your child repeated any class: YesNo If he/she did, please give details: * Have you had any concerns about your child`s early development (e.g. walking, talking)? * What are your main concerns (If any) about your child having this assessment? If you have concerns, please give details: * What are your child`s special talents/abilities? Has your child 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 your child have a hearing test? YesNo Outcome: * Did your child have a sight test? YesNo Outcome: * Does your child have difficulties with any of the following? Dressing/undressing YesNo Tying shoelaces YesNo Closing buttons YesNo Managing cutlery YesNo Hopping/jumping/skipping YesNo Using playground equipment YesNo Riding a bicycle YesNo Using a scissors YesNo Standing on one leg YesNo Walking on walls YesNo Using a scissors or pencil YesNo * Does your child have difficulty with any of the following? Have difficulty making friends YesNo Playing with children his/her own age YesNo Seem unaware of the rules of social conduct YesNo Avoid taking part in team games YesNo Get agitated in crowded places YesNo Seem reluctant to use playground equipment YesNo Misinterpret what is said to him/her YesNo Use formal, adult like language YesNo Get irritated by certain clothing textures YesNo Sometimes speak with an unusual accent YesNo Become upset when routines or plans are changed YesNo Have elaborate routines YesNo If he/she does elaborate routines, please give details Any other information you think may be relevant Consent I/ We consent to a psychological evaluation of my/our son/daughter by Edward Joyce, Psychologist. * Name of Student: Names of both Parents or Legal Guardians: All persons who have legal custody of the child must sign this section. * Father/Legal Guardian: * Mother/Legal Guardian: * Date: Please enter the letters below and then click on the send button.