Ronitte Vilker, Ph.D.

Licensed Clinical Psychologist since 2002

ADULT REGISTRATION FORM

Adult Registration

Name *

First

Last *

Last

Date of Birth *

Gender

Custom Gender

Phone

Email *

Address *

Address

City

State/Province

Zip/Postal

Insurance Information

Insurance

Member ID

Subscriber

Relationship to Patient

Authorization Number

When required by insurance

Insurance Phone

For providers - on back of card

Co-pay

Optional Information

Only fill out if you would like me to have this information prior to our first session.

Living Situation

Current Employment and Work History

Presenting Problem/History of Problem

When did the problem start? Chronic or episodic? How does the problem present at home? At school/work? Where does the problem not occur?

Past Help for the Problem

Previous testing, counseling, tutoring, etc. Issues/diagnoses/doctors/psychiatrists/psychologists

Current Medications

Past Medications

Similar Problems in the Family/Family Composition

Immediate family, extended family, learning disabilities, reading problems, mood or emotional difficulties, etc.

School History

Schools attended, past and present teacher concerns, problems/successes in school, past and present support services, history of IEP or 504 Plan

Social History/Interests and Hobbies

Substance Use

Alcohol/drugs

Trauma History

Has anything of a traumatic nature happened? Accidents? Abuse? Bullying?

Anxiety/Depression Screening Questions

Worries, fears, concerns that affect willingness to complete normal or routine activities, recent changes in interests, appetite, sleep patterns, levels of irritability