Be Kind Psychology — Adult Psychological Assessment Consent & Background Form

Be Kind Psychology — Adult Psychological Assessment Consent & Background Form
Personal Details
1. Full Name*

First NameLast Name
2. Date of Birth*

MonthDayYear
Date
3. Age*
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.
Reason for Referral

Reason for seeking assessment
9. Referral Source/ GP (if relevant)
10. What has led you to pursue a Psychology Assessment?
Background Information
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?
About You
14. What are your interests and passions?
15. How would you describe yourself?
Work/ Education
16. Current Work or College?
Living Situation
17. What is your current living situation? Do you live alone or with others?
Medical History
18. Any significant medical history, allergies, or medications?
Friendships and Relationships
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?
Family
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?
Childhood
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?
Emotional Regulation and Mental Health
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?
Masking
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.)
Sleep and Energy Levels
36. Do you experience any challenges with sleep, fatigue, or maintaining energy levels throughout the day?
Interests
37. Do you have particular interests or areas of focus that bring you joy or help you manage stress?
Planning and Organisation
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)?
Daily Living
40. Do you find any everyday tasks — like cooking, cleaning, shopping, or managing money — particularly difficult or stressful?
Sensory Sensitivities
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?
Educational History
42. What was school like for you?
43. Did you attend college or any further education? What was that experience like for you?
Supports
44. Did you receive any support when you were in school?
45. Is there anything else you would like us to know about you?
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46. Additional Comments or Questions
Consent
Consent for Adult Psychological Assessment

I understand that this assessment is being conducted to explore whether I meet criteria for neurodevelopmental or psychological conditions such as Autism, ADHD, or cognitive differences. It may include interviews, questionnaires, and standardised tests. A formal diagnosis may or may not be made depending on clinical findings.

I understand that this is a diagnostic assessment. It is not a substitute for therapy and does not address all emotional or mental health concerns unless otherwise agreed.

I understand that while every effort will be made to complete the assessment and report in a timely manner, this may vary depending on complexity and the need for clinical judgement. A thorough process will be prioritised over rapid completion.

I understand that Be Kind Psychology and its clinicians cannot guarantee a specific outcome or diagnosis from the assessment process. The assessment will be carried out to the highest professional standard, but any diagnostic conclusions will depend on the information gathered and the clinical judgment of the professionals involved.

I consent to participating in parts of the assessment via secure video call where appropriate.

I consent to the collection and secure storage of personal, developmental, and clinical information relating to this assessment. I understand that this information will be stored in line with professional guidelines and data protection regulations (GDPR).

I understand that information will be treated confidentially in line with GDPR and shared only with my written consent or in circumstances of risk.

I understand that if serious concerns about safety or wellbeing arise during the assessment, these may need to be shared with relevant services in line with safeguarding requirements.

I consent to the secure storage of personal and assessment information in line with GDPR and clinical guidelines.

I understand that the assessment must be paid in advance and that cancellations with less than 72 hours' notice may incur a fee.

I consent to being contacted by email or phone for scheduling and feedback. I understand I will receive a written report following the assessment.

I understand that participation in the assessment is entirely voluntary. I have the right to withdraw from the process at any time without having to provide a reason, and doing so will not result in any adverse consequences or penalties.

I understand that Be Kind Psychology and its team are not liable for actions taken based on the outcome of the assessment.

I release Be Kind Psychology, its employees, and contractors from claims related to the assessment process or outcomes.

I understand that I have the option to include input from a partner, friend, or family member who may be able to provide additional perspective as part of the assessment. This will only be done with my consent.

I confirm that I have read and understood the information provided above. I understand that I can ask questions before providing consent, and may contact info@bekindpsychology.ie with any queries. By signing below, I give my informed consent to proceed with the assessment.
Contact person (if relevant)
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
Date of Consent*

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

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Be Kind Psychology — Adult Psychological Assessment Consent & Background Form

Personal Details

Reason for Referral

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