Child and Adolescent Be Kind Psychology Combined Background History and Consent Form Logo
  • Be Kind Psychology Combined Background History and Consent Form for Psychological Assessment of a Child or Adolescent

    Please complete all of the questions, read the following information carefully and provide your consent for the assessment of your child.
  • Parent and Child Details

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  • Reason for Referral

    Reason for seeking assessment
  • General Description, Strengths and Interests

  • Play and Leisure

  • Family

  • Development

  • Medical History

  • Sensory Sensitivities

  • Peer Relationships and Communication

  • Emotional Regulation and Mental Health

  • Educational History

  • Supports

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  • Consent

  • Consent for Psychological Assessment – Be Kind Psychology

    I consent to my child undergoing a psychological assessment with Be Kind Psychology. I understand that this assessment is being conducted to explore my child’s developmental, cognitive, emotional, or behavioural profile. It may involve evaluating for conditions such as Autism, Attention-Deficit/Hyperactivity Disorder (ADHD), learning differences (e.g. dyslexia), intellectual disability, or global developmental delay. I understand that this process may or may not result in a formal diagnosis.

    I understand that the assessment may include parent interviews, direct observations (e.g. ADOS), developmental history-taking, mental health screening, questionnaires, cognitive or educational testing, and other standardised measures, as appropriate.

    I understand that the scope of the assessment is based on clinical need and agreed in advance. While preferences are considered, the final decision on the type and depth of assessment rests with the Lead Clinical Psychologist. The Autism assessment may or may not include cognitive testing, depending on my child’s profile and clinical presentation.

    I confirm that I have read the information provided prior to booking, including the Fees & Payment Policy, and I understand what is included in the service. I accept that the quoted fee covers the assessment agreed and cannot be altered once commenced.

    I understand that this assessment is conducted for the purpose of identifying or ruling out specific neurodevelopmental or psychological conditions. It is not a treatment or therapy service unless otherwise agreed in advance. Any recommendations will be based on presenting concerns and the assessment scope as agreed.

    I understand that diagnostic conclusions are based on the professional judgement of the clinicians involved, informed by the data collected. A specific outcome or diagnosis cannot be guaranteed.

    I acknowledge that Be Kind Psychology provides professional psychological assessments in line with evidence-based standards. Its clinicians, employees, and contractors are not liable for decisions or outcomes arising from the assessment process, including those relating to education, legal, or therapeutic matters.

    I understand that relevant case information may be discussed within the clinical multidisciplinary team to support diagnostic formulation and ensure best practice.

    I understand that Be Kind Psychology aims to complete the assessment and issue a written report within a reasonable timeframe. This may vary based on assessment complexity, the availability of collateral information (e.g. school input), and the level of clinical interpretation required.

    I understand that school or preschool input may be requested via questionnaire. I consent to this input being considered and included in the final report. I understand that school observation is not included as standard and may involve additional cost if required.

    I consent to the secure collection, processing, and storage of personal, developmental, and clinical data in line with GDPR. I understand that information will remain confidential unless required by law or in cases of safety concerns.

    If significant concerns about safety or wellbeing arise during the assessment, I understand that this information may be shared with appropriate services in line with safeguarding responsibilities.

    I understand that if the ADOS is used during the Autism assessment, the session may be video-recorded for internal clinical review. I consent to this, and understand recordings will be stored securely and deleted once the diagnostic process is complete.

    I consent to parts of the assessment process being conducted via secure video call, where appropriate.

    I understand that the full assessment fee must be paid in advance. If I cancel the assessment with less than five working days’ notice, I understand that no refund can be provided. A €250 administration fee applies to any cancellations prior to this point. Once the assessment has begun (including background interview or form review), fees are strictly non-refundable.

    I consent to being contacted by Be Kind Psychology via email or phone for scheduling, feedback, and report delivery.

    I understand that participation in the assessment is voluntary and that I may withdraw at any time. I also understand that withdrawing after the process has started will not result in a refund.

    I release and hold harmless Be Kind Psychology, its employees, contractors, and agents from all claims or liabilities arising from the assessment process or its outcomes.

    By signing below, I confirm that I have read and understood the above information, and I give my informed consent for my child’s psychological assessment with Be Kind Psychology. I understand that I may contact the clinic at info@bekindpsychology.ie if I have any questions.

  • If you have any questions about this process, you are welcome to contact us at hello@bekindpsychology.ie.

    A written report will be provided following the assessment. A feedback session will be offered to discuss the findings and recommendations

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  • By signing below, I confirm that the information provided is accurate and I give informed consent for this assessment.

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  • Sole Consent in Absence of Signature from Second Parent/Guardian In cases where only one parent/guardian is signing this consent form, the undersigned parent/guardian acknowledges and accepts the following: 

    Sole Responsibility: 
    I, the undersigned parent/guardian, take full and complete responsibility for providing consent for the Psychology assessment of my child. I acknowledge that the other parent/guardian has either refused to sign this form or is unavailable to provide consent. I understand that any dispute, disagreement, or legal action that arises as a result of the second parent/guardian's lack of consent is my sole responsibility, and Be Kind Psychology will not be held liable for any such matters. 

    Indemnity: 
    I hereby agree to indemnify and hold harmless Be Kind Psychology, its employees, agents, and contractors from any claims, disputes, legal actions, or damages that may arise from the absence of consent from the second parent/guardian. This indemnification includes, but is not limited to, disputes related to parental rights, custody arrangements, or any legal claims made by the non-signing parent/guardian regarding the assessment process or its results. 

    Confirmation of Full Authority: 
    By signing this consent form, I confirm that I have the legal authority to provide consent on behalf of my child for the purposes of this autism assessment, and that I am acting in the best interests of my child in doing so. 

     

     

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  • Fees & Payment Policy Agreement

  • Please read the following carefully. This section outlines the terms of payment, cancellation, and clinical scope for assessments carried out by Be Kind Psychology.

    Assessments are agreed in advance based on clinical judgement and presenting concerns. Fees are fixed, all-inclusive packages. They cover all components required to reach a well-supported clinical conclusion, including clinical interviews, testing, scoring, interpretation, written report, and feedback session. There are no hidden charges.

    Full payment is required in advance to confirm your booking. Assessment work will not begin until payment has been received. A 50/50 split payment may be offered in limited cases and must be agreed in writing.

    Cancellations made with more than 5 working days’ notice may be eligible for a refund, minus a €250 non-refundable fee to cover preparation and scheduling.
    Cancellations with less than 5 working days’ notice are non-refundable.
    Once the assessment has started (including background interviews or form review), no refund will be offered.

    The final decision on the type and scope of assessment rests with the psychologist and may not be altered once the process begins. Where additional needs are identified, a broader assessment may be recommended, with additional fees discussed if relevant.

    By signing below, you confirm that you understand and accept these terms.

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