Domiciliary Care Allowance Specialist’s Report (Dom Care 3)

• Published date: 05 July 2021
• Issuer: Department of Social Protection

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Domiciliary Care Allowance

Specialist’s Report

Social Welfare Services

Dom Care 3

Data Classification R

If your child is being treated by more than one specialist and you are submitting a report from each,

please ensure you use a separate report form for each specialist.

PPS Number:

Surname:

Date of birth:

First names:

D D M M Y Y Y Y

Child’s details

Primary diagnosis:

ICD10 Codes:

Other diagnosis:

ICD10 Codes:

Other diagnosis:

ICD10 Codes:

Other diagnosis:

ICD10 Codes:

Diagnoses

Please list the assessment tools used to reach these diagnoses. See example below:

Assessment tool Date

Weschler Intellectual Scale for Children/WISC 12/10/2019