Be Kind Psychology - Adult Psychological Assessment Consent & Background Form

Completion of this form does not guarantee a specific diagnosis. Assessment recommendations are based on the information provided and the clinical judgement of the assessing psychologist.

1. Full Name*

First NameLast Name

2. Date of Birth*

Date

4. Pronouns

5. Occupation/ Current Role

6. Contact Email*

example@example.com

7. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

8. Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

9. Referral Source/ GP (if relevant)

10. What has led you to pursue a Psychology Assessment?

Typical developmentDelayed speechDelayed walkingOther

11. Do you have a history of any prior diagnoses or assessments (e.g., ADHD, autism, learning difficulties, mental health)?

12. Are there any current aspects of your life you’d like to explore (e.g., attention, sensory differences, relationships)?

13. Are there any aspects of work, education, or daily life that you find more difficult or need extra support with?

14. What are your interests and passions?

15. How would you describe yourself?

16. Current Work or College?

17. What is your current living situation? Do you live alone or with others?

18. Any significant medical history, allergies, or medications?

19. Do you have a partner or spouse? Are you currently in a relationship?

20. Are friendships something that matter to you? Have you ever found it hard to make or keep friends — for example, feeling different from others, finding social situations confusing, or having difficulty staying in contact?

21. How do you prefer to communicate with others? What are your preferences? In person, over the phone, via text, messaging, email?

22. How do you find social situations and relationships?

23. Do you have any family history of neurodivergence or mental health concerns?

24. Tell me about your family? Is there any significant family history

25. Is there anything about your family’s living situation or background that may be important for us to know?

26. What was it like for you growing up?

27. Did you experience any adversity or trauma growing up?

28. Have you ever experienced bullying or exclusion at school, in the workplace, or in social situations?

29. Do you have a history of mental health concerns (e.g., anxiety, depression, trauma)?

30. How do you respond to changes in your life?

31. Do you ever find it hard to manage big feelings — like getting very upset, feeling overwhelmed, having mood swings, or shutting down? If so, can you describe what that’s like for you?

32. Have you developed any strategies to manage strong emotions (e.g., self-soothing, avoidance, masking, or seeking support)?

33. Have you ever received support from other professionals? (e.g., Psychiatry, SLT, OT, psychology)?

34. Are there any stresses or life events we should be aware of?

35. Do you feel that you often mask or hide aspects of yourself in social, work, or educational settings?(For example, rehearsing conversations, copying others’ behaviours, or suppressing stimming or strong emotions.)

Masking behaviors (e.g., rehearsing conversations, copying others’ behaviors, forcing eye contact, hiding stimming)

36. Do you experience any challenges with sleep, fatigue, or maintaining energy levels throughout the day?

37. Do you have particular interests or areas of focus that bring you joy or help you manage stress?

Intense or long-term interests that become very absorbing

38. Do you ever find things like planning, staying organised, managing time, or finishing tasks difficult? (For example, forgetting appointments, losing things, putting things off, getting stuck starting or finishing something, or feeling overwhelmed by tasks with lots of steps.)

39. Have you developed any strategies to help manage these challenges (e.g., lists, reminders, visual aids, support from others)?

40. Do you find any everyday tasks — like cooking, cleaning, shopping, or managing money — particularly difficult or stressful?

41. Are you sensitive to certain things like sounds, lights, textures, or foods — or do you seek out certain sensations, like movement, pressure, or specific sounds?

42. What was school like for you?

43. Did you attend college or any further education? What was that experience like for you?

44. Did you receive any support when you were in school?

45. Is there anything else you would like us to know about you?

Upload any reports here

Consent for Adult Psychological Assessment

Purpose of Assessment
The assessment is conducted to explore whether you meet criteria for neurodevelopmental or psychological conditions such as Autism, ADHD, or cognitive differences. It includes clinical interviews, questionnaires, and standardized psychological tests.

Nature of Assessment
This is a diagnostic assessment and not ongoing therapy unless separately arranged. A formal diagnosis cannot be guaranteed and conclusions are based on the information available at the time. Additional information may influence diagnostic conclusions.

Confidentiality and Data Protection
Personal information and assessment records will be stored securely and retained in accordance with professional ethical record-keeping standards and the General Data Protection Regulation (GDPR). Limits of confidentiality include risk to self or others or legal obligations to disclose.

Voluntary Participation
Participation is voluntary. You may withdraw at any time, but if you do, the assessment may not be completed and a diagnostic opinion may not be provided.

Assessment Outcomes
Following completion, you will receive a written report summarizing findings and recommendations. The time required may vary depending on complexity.

If you have any questions, please contact us at info@bekindpsychology.ie.

Assessment Agreement and Payment Policy

By proceeding with an assessment with Be Kind Psychology, you understand and agree to the following terms.

Assessment fees are fixed, all-inclusive packages covering the full diagnostic process. This includes clinical interviews, administration of assessment tools, scoring and interpretation of results, preparation of a comprehensive written psychological report, and a feedback session.

A 20% non-refundable booking deposit is required to secure assessment appointment(s). This deposit confirms the booking and covers the clinical time reserved, administrative processing, and preparatory work undertaken in advance of the assessment.

Two invoices are issued at the outset via Stripe: one for the booking deposit and one for the remaining balance.

The remaining balance must be paid in full no later than two weeks before the assessment begins. Assessment work will not commence unless payment has been received in full by this time.

Once the assessment type and appointment(s) have been agreed and the booking deposit has been paid, the scope of the assessment is considered confirmed and cannot be altered.

Assessment appointments involve significant preparation and the reservation of specialist clinical time.

Fees paid are non-refundable if an assessment is cancelled. Once any part of the assessment process has commenced (including interviews, record review, scoring, or testing), fees are strictly non-refundable.

If a client chooses not to proceed after the assessment process has begun, fees remain payable for work already undertaken including interviews, review of records, scoring, interpretation, and report preparation.

If an assessment appointment needs to be rescheduled due to illness or unforeseen circumstances, the appointment will be rescheduled where possible and fees paid will remain valid for the new appointment date.

Protective Clauses:

Completing forms or paying a deposit does not guarantee any diagnosis or outcome.
Conclusions are based on information available at the time and may change if additional information becomes available.
The written psychological report reflects the clinician’s professional opinion and cannot be altered or reproduced without written permission.

The purpose of the assessment is to provide diagnostic clarification and professional recommendations. The assessment process cannot guarantee a specific diagnosis or outcome, as conclusions depend on the information gathered and the clinical judgement of the assessing clinician.

Third-party organisations may have their own criteria for accepting psychological reports and Be Kind Psychology cannot guarantee external acceptance of recommendations.

If you have any questions, please contact us at info@bekindpsychology.ie.

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

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

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

Signature*

Be Kind Psychology - Adult Psychological Assessment Consent & Background Form

Personal Details

Reason for Referral

Early Development

Background Information

About You

Work/ Education

Living Situation

Medical History

Friendships and Relationships

Family

Childhood

Emotional Regulation and Mental Health

Masking

Sleep and Energy Levels

Interests

Planning and Organisation

Daily Living

Sensory Sensitivities

Educational History

Supports

Consent