Primary School Form – Completed By Parent/Guardian

Referral Form for a Psychological Assessment Private & Confidential

    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:

    * Physiotherapist: YesNo
    Date Assessed:

    * Occupational Therapist: YesNo
    Date Assessed:

    * Speech and Language Therapist: YesNo
    Date Assessed:

    * Paediatrician: YesNo
    Date Assessed:

    * Did your child have a hearing test? YesNo

    * Did your child have a sight test? YesNo

    * 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


    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:
    I consent to Edward Joyce Privacy Policy Terms, for more information click here.
    Please enter the letters below and then click on the send button.