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Contact details

Child's First Name

Child's Last Name

Child's DoB (dd/mm/yyyy)

Mother's Full Name

Father's Full Name

Address 1

Address 2

Address 3

City/Town

County
—Please choose an option—AntrimArmaghCarlowCavanClareCorkDerryDonegalDownDublinFermanaghGalwayKerryKildareKilkennyLaoisLeitrimLimerickLongfordLouthMayoMeathMonaghanOffalyRoscommonSligoTipperaryTyroneWaterfordWestmeathWexfordWicklow

Eircode

Your Full Name

Contact Phone Number

Contact Email Address

School and Educational Details

What class is your child in
—Please choose an option—Junior InfantsSenior InfantsFirst ClassSecond ClassThird ClassFourth ClassFifth ClassSixth ClassOther

Name of the school they attend

Is your child currently receiving resource teaching/ learning support at school?
YesNo

Please provide details (if you know) of how many days and for how long?

Has your child already received as assessment by an educational psychologist?
YesNo

If you answered ‘yes’ above, what was diagnosed? (e.g. dyslexia, dyspraxia, ASD, DLD, etc)
—Please choose an option—DyslexiaDyspraxiaASDDLDOther

Please provide details if you answered ‘other’ above

When was the assessment done? (dd/mm/yyyy)

Has your child been receiving other private tuition outside normal school hours
YesNo

If you answered ‘yes’ to the last question can you please provide some details as to the duration of that individual help and how many hours per week, done in your own home or in school building etc?

Can you describe your concerns in relation to your child?

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