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If you have any communication barriers (e.g., hearing impairment, language needs, learning difficulties, ADHD-related processing difficulties, etc.) that we can assist with during your appointment, please outline these under “Reason for Visit.” If none apply, please state:

I do not have any communication barriers requiring additional support.

If you do not consent, please leave this box blank. While we respect your decision not to inform your GP about your consultation, the clinician reserves the right to contact your GP if they believe it is in your best interests or there is a safety concern. You will be informed of any such decision during or after the consultation.
If you are experiencing active suicidal thoughts or are in crisis, please contact:
  • Your local GP
  • Samaritans Ireland (116 123)
  • Emergency Services (999 or 112)

Patient Details

If you have any communication barriers (e.g., hearing impairment, language needs, learning difficulties, ADHD-related processing difficulties, etc.) that we can assist with during your appointment, please outline these under “Reason for Visit.” If none apply, please state:

I do not have any communication barriers requiring additional support.

If you do not consent, please leave this box blank. While we respect your decision not to inform your GP about your consultation, the clinician reserves the right to contact your GP if they believe it is in your best interests or there is a safety concern. You will be informed of any such decision during or after the consultation.
If you are experiencing active suicidal thoughts or are in crisis, please contact:
  • Your local GP
  • Samaritans Ireland (116 123)
  • Emergency Services (999 or 112)