Consent Form For Psychological Assessments printable pdf download

2015-2016 SCPA FORM 1

Scheme for the Commissioning of Psychological Assessments (SCPA)

CONSENT FORM

1. Having discussed the matter with the school principal, I/we consent to the assessment of my/our

daughter/son by a psychologist commissioned by the school and on the SCPA panel. I/we

understand that the assessment may include an individual interview with my/our daughter/son

and/or the administration of psychological tests by the psychologist.

2. I/we understand that the outcome of this assessment will be made known to me/us and to the

principal and, where the principal considers it appropriate, to other relevant members of the school

staff.

3. I/we consent to having a copy of my/our child’s psychological report sent to the DES/NEPS. In

consenting to this, the following applies -

The Minister for Education and Skills, and his or her servants or agents, may hold and process information which has been

gathered arising from the psychologist's work with your child. This may include, but not necessarily be limited to, referral

information, results of any assessments, records of the work carried out by the psychologist and findings recorded by the

psychologist. A summary of this information will be held in an electronic format. A person has a right under the Freedom of

Information Acts 1997 and 2003 to apply for access to records containing this information. The information will be treated as

confidential information or personal information, or both, for the purposes of the Freedom of Information Acts.

For the purposes of the Data Protection Acts 1988 and 2003, the information will form part of the personal data of the

Minister for Education and Skills. The purpose of holding this information is to assist with the performance of assessment,

which may include consultation with other relevant third parties, making of recommendations, case management and

preparation of statistical information. The Minister for Education and Skills may also supply all or part of the information to

third parties as appropriate for these purposes. A person has a right to request a copy of the personal data relating to him or

her which the Minister for Education and Skills holds.

Psychological reports and information provided to the DES/NEPS under the scheme may be used by the DES/NEPS to monitor

the quality of the service, to ensure the provisions of the scheme are being complied with, to enable it to consider the adequacy

of educational provision in particular cases and/or to assess, plan and coordinate educational strategy and delivery in respect

of children with special educational needs generally.

By signing this form, THE UNDERSIGNED consent to the collection and use of the information as described.

Name of Child: ..……………………………………………………….

Date of Birth: ...........…………….

School: …………………………………………………...……………

Class/Year: …..…………………..

Home Address:……………………………………………………………………………………………………

……………………………………………………………………………………………………………………

………………………………………………………………………..Tel. No.:…………………………………

IMPORTANT: The legal guardian(s) of the child should sign below

Mother or Legal Guardian (1)

Father or Legal Guardian (2)

Telephone Number:

Date:

Consent Form For Psychological Assessments