Patient Registration

Patient Registration

Thank you for choosing the The NeuroCognitive & Behavioral Institute as your healthcare provider. Please complete this patient registration form with your information and our staff will contact you shortly. Registration is open to residents of United States only. By submitting this form, you consent to a diagnostic evaluation. Please note that we utilize artificial intelligence technology to analyze your test data.
Patient Status*
Patient's Legal Name*

First NameLast Name
Each patient must have a unique email address to create their personal scheduling portal account. Please enter the email you would like to use as your login. If you are registering multiple patients, ensure that each patient is registered separately and has a distinct email address to access the scheduling portal.*

Confirmation Emailexample@example.com
A parent/caretaker is filling out this form on the patient's behalf*

NoYes
Caretaker Name*

First NameLast Name
Caretaker Email*
example@example.com
Caretaker Mobile Number*
Please enter a valid phone number.
Patient's Preferred Name

First NameLast Name
Pronouns
Date of Birth*

MonthDayYear
Date
Patient Age*
Gender at Birth*

MaleFemale
Patient Primary Address -- We May Ship Materials to Your Home for Your Assessment -- Please verify!*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country*
Geolocation
IP Country
Patient Email (do not repeat caretaker email)*
example@example.com
Patient Mobile Phone Number (do not repeat caretaker mobile number)*
Please enter a valid phone number.
Consult Reason*
Please describe why you are seeking our services. Example: I struggle with ______.
The patient interested in:*

Counseling/Psychotherapy Services onlyA full neuropsychological evaluation onlyBoth Counseling/Psychotherapy Services and a full neuropsychological evaluation
If you wish to receive a standard neuropsychological evaluation, please indicate if you are also interested in receiving any of the following:*

Learning Disability AssessmentAutism AssessmentNone of the above
Preferred Location*

Bedminster, NJLivingston, NJMt. Arlington, NJTelehealth, NJTelehealth, US States EXCLUDING NJ
Preferred Evaluation Modality: (For Hybrid and Telehealth, please ONLY check if you meet the following requirements: 1. Own a personal computer. 2. Can navigate the PC independently. )*

In Clinic OnlyTelehealth OnlyHybrid (Combo of In clinic and Telehealth appointments)
Does the patient own a personal computer with a camera and microphone? (For Hybrid and Telehealth options)*

YesNo
Can the patient navigate a personal computer independently? (For Hybrid and Telehealth options)*

YesNo
ERROR Please Modify Your Selection: The Patient Must Have a Working PC AND Be Able to Navigate the PC Independently for Telehealth and Hybrid Options. Please select "Yes" in the previous two sections or select "In Clinic Only"
ERROR Please Modify Your Selection: The Patient Must Have a Working PC AND Be Able to Navigate the PC Independently for Telehealth and Hybrid Options. Please select "yes" in the previous two sections or select "In Clinic Only"
If Hybrid or Telehealth modality was selected, do you have access to a printer to print out materials for your assessment*

N/A, I did not select Hybrid or TelehealthYes, I have a printer where I can clearly print several documents (~ 40 pages)No, I do not have a printer
If Hybrid or Telehealth modality was selected, do you have a phone stand that can be adjusted 360 degrees*

N/A, I did not select Hybrid or TelehealthYes, I have a phone stand that I can use for my evaluationNo, I require that this be mailed to me
Language Patient is Most Proficient In. If English, skip.
Referring Provider/ Primary Care Physician Name*
Please ensure we receive your relevant medical records ahead of any appointments.
Other Referral Source: (If not referred by a Physician)
Health Insurance*

I have health insuranceI would like to speak to the finance department to explore out of pocket costs
The patient has Medicaid as their primary insurance*

YesNo
Name of Primary Insurance Holder*
Primary Insurance Company*
Primary Insurance ID Number*
Front of Primary Insurance Card*
Back of Primary Insurance Card*
Secondary Insurance*

I have secondary insurance that I'd like to use.I have no secondary insurance.
Name of Secondary Insurance Holder*
Secondary Insurance Company*
Secondary Insurance ID Number*
Front of Secondary Insurance Card*
Back of Secondary Insurance Card*
How did you hear about NCBI*
Which Center are you interested in

The Neurodevelopmental Disorders Diagnostic and Treatment CenterThe Mind-Body Neuropsychiatric and Mental Health Disorders CenterThe Sleep Study and Treatment CenterThe Center for Acquired and Traumatic Brain InjuriesThe Center for the Prevention and Treatment of Neurodegenerative DiseasesAll

Please let us know the days and times you are generally available for appointments. We typically schedule appointments as early as 6 weeks out, so include any consistent openings you might have.*

	Morning (9am–12pm)	Afternoon (12pm–4pm)	Evening (4pm–7pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Anything else we should know about your availability?
Would you like to receive email updates about NCBI*

Yes, subscribe me to emails about NCBINo
Marketing Permissions

EmailDirect MailCustomized Online Advertising
*Registration is open to residents of the United States only.
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