Booking Form
Full Name
*
First Name
Last Name
Contact Number
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Birth:
*
DD/MM/YYYY
Would you like to book:
*
Please Select
Autism Assessment (€1400)
Screening Appointment (€300)
Would you prefer your appointments to be in-person in Sligo or online?
*
Please Select
In-Person in Sligo
Online (Teams)
If booking an online assessment, would you prefer to have the assessment in one day over three hours (usually an appointment from 9.30am until 12.30pm) or to split the three hours over a two week period (in terms of having three one-hour appointments)?
*
Please Select
Assessment held in one day over three hours
Assessment as three one-hour appointments
Not Applicable for Screening Appointments or in-person assessments
I consent to Branchfield Clinic emailing me password protected documents containing information relating to progressing this booking (while accepting that as with any email transmission, there is a small risk of a third party accessing this information).
*
Please Select
Yes
Your personal information is treated with respect and privacy to be read only as needed, in accordance with GDPR and the Psychological Society of Ireland guidelines. Your information will be held securely in accordance with GDPR guidelines and is automatically deleted after 3 months if you chose not to proceed with this booking. You may always request to see what information is held about you at any given time, allowing notice to gather and share as per GDPR guidance.
*
Please Select
I consent
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