Cocoon Clinical Psychology Services

Your Name

Phone number

Eircode/Address

Email

Name of person referred

Date of birth of person referred

How did you hear about Cocoon Clinical Psychology

Google Search

Psychology Society of Ireland (PSI) Website

Psychology Today Website

Instagram post

Facebook post

GP/Health professional

Teacher

Friend or relative

Other

Risk declaration.

My referral is not related to immediate risk of harm to any individual. I understand that this is not a crisis response service. If you or someone you know is at risk of self harm or reporting suicidal thoughts, please contact Pieta House, A&E department of your local hospital or another 24 hour emergency support service. I declare that I am aware who to contact in a crisis.

Required service

I am interested in

Consultation only

Assessment for myself

Assessment for my child

1:1 Therapy sessions for myself (Waitlist currently 6-8wks)

1:1 Therapy session for a child (Waitlist currently 10-12wks)

Self-directed parenting support (webinars/courses with tailored remote clinician support)

Self-paced online therapy for teens/adults (with tailored therapy plan and remote clinician support)

Something else....

I have read Cocoon Clinical Psychology's Privacy Statement and Cancelation Policy and I agree to the processing of my personal data for the purposes of clinical therapy and/or assessment

Questions or concerns which have brought me here today

Do all legal Guardians of the referred person agree to this referral?

Yes / Not applicable

No

No. But I am seeking only information and support for myself in relation to my parenting responsibilities at this time.

The referred person has been assessed or linked with services previously. Check All That Apply

Psychologist

Occupational Therapist

Speech and Language Therapist

Hospital Paediatrician

Tusla family support

CAMHS

CDNT - Disability services

Adult mental health team / Psychiatry

NEPS / educational assessment

Psychotherapist, play therapist or other

No previous services

I am concerned about the following areas. Check All That Apply

Emotional and behavioural development

Social communication and skills / ASD

Anxiety / OCD / Phobias

Low mood / reduced motivation

Attention and Activity levels / ADHD

Eating or toileting issues

Sleep issues

Anger / aggression / outburst behaviours

Learning difficulties and cognitive performance

Motor skills and/or sensory challenges

Delayed language or speech issues

Other concerns

Any other information you think may be relevant to this referral...

Consultation available within 2 weeks.

Booking Form.

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Email Me

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