Book an appointment for your child.

Please provide as much information as you can to ensure we can provide you with the best support.

Childs name

Parent name

Email

Phone

Birthday

Day

Month

Year

Address

We request Next of Kin details for your Childs safety and in case of an emergency.

Next of Kin Phone number

Next of Kin relationship to you

GP Name

GP Practice

How did you hear about us?

Please indicate your availabilty for appointments

Would you prefer an online or face-to-face appointment? Online sessions offer the same professional support with greater flexibility and shorter wait times. *

Online

Face to face

No preference (Soonest available)

What are your main reasons for seeking an appointment for your child?

Is your child experiencing thoughts of self harm?

Is your child experiencing suicidal ideation?

Has your child had previous counselling or psychotherapy? Please describe (in the text box below) your experience of therapy, what kind of therapy it was e.g. CBT, grief counselling etc. and whether you had a positive or negative experience.

Are you engaged with any other services? Please outline whom, how long you have been working with them & the nature of your relationship with them. E.g Psychiatry, Speech & Language Therapy, Addiction services, Pieta house etc.

Preferred therapist (Please Tick all that apply). You can find out more about our psychologists here https://www.mypsychologyireland.com/meettheteam*

If your preferred therapist has a waiting list would you like to be seen sooner by another therapist?

Yes I am happy to seen by a therapist that has availability (online or in person)

Yes but I would prefer to be seen by an in person therapist only

No I would prefer to wait for my selected therapist.

We employ helpful and pleasant reception and administration staff who will be pleased to answer any general queries you may have. Our receptionist assists the psychologists to arrange appointments, welcome you to the office, answer your queries, take minutes at meetings and carry out administration tasks. Everything that you tell them is treated in confidence. They work on a part time basis so we would ask you to allow us 48 hours to respond to any queries. Please check to confirm you understand

I understand that payment is required in advance of my session and that cancellations with less than 48 hours’ notice will be fully charged. I acknowledge that if I miss my session without notice, I may still be responsible for the full fee.*

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