Ronitte Vilker, Ph.D.

Licensed Clinical Psychologist since 2002

CHILD REGISTRATION FORM

 

Child Registration
First
Last
Patient Address *
Patient Address
City
State/Province
Zip/Postal
Insurance Information
When required by insurance
For providers - on back of card
Optional Information

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

Parent’s names, marital status, if not in one household - visitation, siblings, pets
When did the problem start? Chronic or episodic? How does the problem present at home? At school? Where does the problem not occur?
Previous testing, counseling, tutoring, etc. Issues/diagnoses/doctors/psychiatrists/psychologists
Immediate family, extended family, learning disabilities, reading problems, mood or emotional difficulties, etc.
Schools attended, past and present teacher concerns, problems/successes in school, past and present support services, history of IEP or 504 Plan
Neonatal; Jaundiced? Routine?
Walking, talking, fine motor, toilet training, etc.
Problems understanding or remembering language, trouble pronouncing words with many syllables, trouble finding words, trouble following directions, problems expressing needs, ideas, etc.
Picky about food, clothing, tags, sound, touch
Running, balance, coordination, use of playground equipment, coloring, use of scissors, preferred types of toys, play activities that are avoided
History of ear infection, allergies, frequent congestion, hospitalization/accidents/surgeries, high fevers/convulsions/head injuries, chronic conditions/residual problems/physical limitations, medications/side effects from medications, sleep patterns/eating patterns, usual sensory sensitivities - touch, sounds, temperature, clothing, etc. primary care physician
Parents Married?
Alcohol/drugs - if relevant
Has anything of a traumatic nature happened in the child’s oradolescent’s lifetime? Accidents? Abuse? Excessive teasing?
Ability to sustain mental effort during activities other than TV or the computer, organization and planning skills, forgetfulness/losing materials, homework completion, number of reminders needed to complete a task, overall activity level, ability to complete one task before starting another task, distractibility levels in different settings
Worries, fears, or concerns that affect willingness to complete normal or routine activities, recent changes in interests, appetite, sleep patterns, levels of irritability