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Ronitte Vilker, Ph.D.
Licensed Clinical Psychologist since 2002
ADULT REGISTRATION FORM
Adult Registration
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Past Help for the Problem
Previous testing, counseling, tutoring, etc. Issues/diagnoses/doctors/psychiatrists/psychologists
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Similar Problems in the Family/Family Composition
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School History
Schools attended, past and present teacher concerns, problems/successes in school, past and present support services, history of IEP or 504 Plan
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Substance Use
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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
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