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:

    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:

    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.
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