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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