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About Us
Overview
Bios & Directory
Clinical Centers
Sleep Study and Treatment
Prevention and Treatment of Neurodegenerative Diseases
Acquired and Traumatic Brain Injuries
Mind-Body Neuropsychiatric and Mental Health Disorders
Neurodevelopmental Disorders
Careers
Locations
Contact NCBI
Clinical Services
Diagnostics
Neuropsychological Testing
Brain Mapping
ANS Testing
Specialty Tests and Exams
Treatments
Psychotherapy
Neuromodulation
Neurocognitive Rehabilitation
Sleep Disorder Treatment
Telehealth
Research
Overview
NCI Foundation
Clinical Trials at NCBI
Patient Services
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Pay My Bill
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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
*
Please Select
New Patient
Current Patient (Registered more than 6 months ago)
Patient's Legal Name
*
First Name
Last Name
A parent/caretaker is filling out this form on the patient's behalf
*
No
Yes
Caretaker Name
*
First Name
Last Name
Caretaker Email
*
example@example.com
Caretaker Mobile Number
*
Please enter a valid phone number.
Patient's Preferred Name
First Name
Last Name
Pronouns
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Age
*
Gender at Birth
*
Male
Female
Patient Primary Address -- We May Ship Materials to Your Home for Your Assessment -- Please verify!
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Location:
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 only
A full neuropsychological evaluation only
Both 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 Assessment
Autism Assessment
None of the above
Preferred Location
*
Bedminster, NJ
Livingston, NJ
Mt. Arlington, NJ
Telehealth, NJ
Telehealth, 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 Only
Telehealth Only
Hybrid (Combo of In clinic and Telehealth appointments)
Does the patient own a personal computer with a camera and microphone? (For Hybrid and Telehealth options)
*
Yes
No
Can the patient navigate a personal computer independently? (For Hybrid and Telehealth options)
*
Yes
No
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 Telehealth
Yes, I have a printer where I can clearly print several documents (~ 40 pages)
No, I require that this be mailed to me
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 Telehealth
Yes, I have a phone stand that I can use for my evaluation
No, 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 insurance
I would like to speak to the finance department to explore out of pocket costs
The patient has Medicaid as their primary insurance
*
Yes
No
Primary Insurance Company
*
Name of Primary Insurance Holder
*
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.
Secondary Insurance Company
*
Secondary Insurance ID Number
*
Name of Secondary Insurance Holder
*
Front of Secondary Insurance Card
*
Back of Secondary Insurance Card
*
How did you hear about NCBI
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Word of mouth
Family and friends
Search Engine (eg google)
Facebook/Instagram
Youtube
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Other Website
Fax
Email
Fyler/Brochure
Insurance company
Referring Physicians
Other
Which Center are you interested in
The Neurodevelopmental Disorders Diagnostic and Treatment Center
The Mind-Body Neuropsychiatric and Mental Health Disorders Center
The Sleep Study and Treatment Center
The Center for Acquired and Traumatic Brain Injuries
The Center for the Prevention and Treatment of Neurodegenerative Diseases
All
Would you like to receive email updates about NCBI
*
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No
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*Registration is open to residents of the United States only
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