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.
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