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Patient Registration

Patient Registration and History Form

Thank you for choosing the NeuroCognitive & Behavioral Institute as your healthcare provider. To register yourself as a patient or to register a patient, please complete this patient registration and history form. Once submitted you will receive an email with instructions to schedule your diagnostic assessments. By submitting this form, you consent to a diagnostic evaluation for the patient being registered for the assessment and acknowledge that some or all of the procedures may be conducted via Telehealth interactions between the patient and when necessary a caregiver and the clinicians and technicians conducting the evaluation. Please also note that we utilize artificial intelligence technology to assist in the analysis of your test data. NCBI also has contracts with HIPAA business associates to ensure the privacy and security of each patient's personal health information.
Permission to Participate in Telehealth Consultation and Treatment

1. Purpose: The purpose of this Telehealth Permission Form is to get permission from patients to use the telehealth services during the treatment.

2. Medical Information & Records: Medical history and test details can be discussed with other healthcare professionals. The patient will be contacted via video and audio or audio only during a telehealth appointment/visit. Video, audio, or any other digital photo of the patient can be recorded during the telehealth visit for treatment purposes only. Information will be protected under HIPAA.

3. Patient Rights: The patient can withhold or withdraw the consent or permission to telehealth consultation/treatment at any time.

4. Limitations: The telehealth appointment/visit will be similar to the regular office or in-clinic visit. Because this service uses videoconference technology, the visit may not be equivalent to or adequate as the regular in-clinic visit. The patient may be recommended a visit physically after the telehealth visit by his or her healthcare provider for certain services. Telehealth has limitations compared to in-person consultations, including the potential for technical issues.

I have been informed about the potential limitations, benefits of the telehealth practices and confidentiality of personal and medical information, and records. The opportunity to ask questions had been given to me and they were answered completely. I have understood the information and I have given my permission to participate in Telehealth Consultation.
Patient Status*
Patient's Legal Name*

First NameLast Name
A parent/caretaker is filling out this form on the patient's behalf*

YesNo
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.
Patient Email (caretaker email entered below)
example@example.com
Caretaker Email
example@example.com
Auto emails go to:
example@example.com
Patient's Preferred Name

First NameLast Name
Pronouns
Date of Birth*

MonthDayYear
Date
Confirm Date of Birth*

MonthDayYear
Date
DOB does not match!
Gender at Birth*

MaleFemale
Patient Primary Address -- -- Please verify this is the correct address*

Street Address

Street Address Line 2

CityState
Country*
Patient's Age*
Zip code*
Note: for patients receiving all or some of their diagnostic assessment virtually, we might need to ship some materials to your home.
base_clinic
Age-Tier
test
Assigned Clinic
The patient has New Jersey Medicaid as their primary insurance*

YesNo
The patient interested in:*

Mental health services only (e.g., psychotherapy, neuromodulation for a psychiatric disorder or psychopharmacological consultation)A full neuropsychological evaluation
The patient has Aetna as their primary insurance*

YesNo
Patient or Primary Caregiver’s Mobile Phone Number*
Caretaker or Emergency Contact’s Name (if applicable)

First NameLast Name
Caretaker Mobile Number (if different from the patient’s mobile number)
Please enter a valid phone number.
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
Primary Insurance Company
Name of Primary Insurance Holder

First NameLast Name
Primary Insurance ID Number
Front of Primary Insurance Card

Cancelof
Back of Primary Insurance Card

Cancelof
Secondary Insurance

I have secondary insurance.I have no secondary insurance.
Secondary Insurance Company
Name of Secondary Insurance Holder

First NameLast Name
Secondary Insurance ID Number
Front of Secondary Insurance Card

Cancelof
Back of Secondary Insurance Card

Cancelof
How did you hear about NCBI *
Which Center or Centers are you interested in:

The Neurodevelopmental Disorders Diagnostic and Treatment CenterThe Center for Acquired and Traumatic Brain InjuriesThe Sleep Study and Treatment CenterThe Center For Cognitive and Memory Disorders from Neurodegenerative DiseasesThe Mind-Body Neuropsychiatric and Mental Health Disorders CenterAll
During the scheduling process your intake and initial exam will likely be conducted online via our telehealth assessment program. Whereas, testing appointments are scheduled based on availability. This can be either online or in-clinic.

In-clinic visits are assigned to the closest clinic in NJ based on your zip code. For patients who live too far from our New Jersey clinics, your testing will be conducted online using our neurodiagnostic interactive testing platform.
Do you have access to a printer to print worksheets if some of your testing is conducted on line?*

YesNo
Do you have a selfie or other type of phone stand that can be adjusted 360 degrees as this is needed if some of your testing is conducted online?*

YesNo
Does the patient have access to a personal computer, laptop and/or tablet with a camera and microphone?*

YesNo
Can the patient navigate a personal computer independently?*

YesNo
Please indicate if this testing is to assess for*

Learning Disability AssessmentAutism AssessmentAcquired or traumatic brain injury as a possible cause of the patient’s difficultiesSleep related disorder as a possible cause of the patient’s difficultiesPossible neurodegenerative disease as a possible cause of the patient’s difficultiesDisability assessment
Are the patient’s expressive language abilities intact?

YesNo
If expressive language abilities are impaired, is the patient unable to communicate to communicate verbally?

YesNo
Does the patient have Down Syndrome or another moderate to severe intellectual disability

YesNo
Please provide some additional information about the reason you are seeking services at NCBI
Please review and sign and date the NCBI’s NCBI's Financial Policy by clicking the following link and once the financial responsibility party signs you will be directed back to this registration form.
Marketing Permissions

EmailDirect MailCustomized Online Advertising
Would you like to receive email updates about NCBI?*

Yes, subscribe me to emails about NCBI.No
I would like to be contacted if an earlier appointment becomes available due to a cancellation or reschedule.*

YesNo
Patient History Form
I. Patient Information
Race
Ethnicity
Handedness

Right-handedLeft-handedOther
If left-handed: Other left-handed family members?

YesNo
If yes, specify who in the family is left-handed?
What was the patient’s first language spoken fluently?*
Second language learned and spoken fluently? (if applicable)
What is the patient's current primary language?*
What is the patient’s present receptive language abilities?*

IntactMildly-impaired (understands most of what is said to the patient)Significantly-impaired (comprehends very little information)
What is the patient's present expressive language abilities?*

IntactMildly-impaired (speaks in phrases but can communicate through language)Significantly-impaired (no verbal communication)
Patient Educational Information
What is the patient's highest or current level of education?*
Current Grade (for current students only)
Skipped a grade?

YesNo
If grade(s) were skipped, which?
Repeated a grade?

YesNo
If grade(s) were repeated, which?
Is the patient receiving or has the patient ever received an IEP or special education related services?*

YesNo
If special education services are currently or have been received please explain with time periods received
II. Referral Information
Referral Source
The patient is being evaluated due to difficulties with (check all that apply):

Cognitive Functioning/Developmental DelayBehavioral Regulation/Inattention/HyperactivityMood SymptomsSocial Functioning/Concern for Autism Spectrum Disorder
Please explain
Additional info:
Is the assessment related to a disability application or ongoing disability claim?

YesNo
Is the assessment in relation to legal or financial matters (e.g., pending litigation, financial benefit considerations)

YesNo
Is the patient seeking solely psychotherapy services, without an interest in neuropsychological assessment?

YesNo
Medications
If the patient is taking any medications, please list them here:
Please list any relevant past medications:
Treatments, Therapies, and Interventions
In the following section, please indicate any past or present treatment or therapy interventions the patient has undergone. It is important to include details such as the dates, duration of the intervention, and response to the treatment. These details should be included in the Notes column.

None
Treatment/Therapy Type
Psychotropics

CurrentPastNA
Notes
(e.g., age started)
Is the patient receiving psychotherapy?*

YesNo
Notes
(e.g., age started)
Has the patient received psychotherapy in the past?*

YesNo
Notes
(e.g., age started)
School counseling

CurrentPastNA
Notes
(e.g., age started)
Has the patient had any past psychiatric hospitalizations?*

YesNo
Please list any other relevant present treatments related to this consultation.
(e.g., age started)
Please list any other relevant past treatments related to this consultation
(e.g., age started)
ECT (Electroconvulsive Therapy)

CurrentPastNA
Notes
(e.g., age started)
Speech therapy

CurrentPastNA
Notes
(e.g., age started)
Occupational therapy

CurrentPastNA
Notes
(e.g., age started)
Physical therapy

CurrentPastNA
Notes
(e.g., age started)
Cognitive rehabilitation

CurrentPastNA
Notes
(e.g., age started)
ABA or behavioral therapy

CurrentPastNA
Notes
(e.g., age started)
Social skills group

CurrentPastNA
Notes
(e.g., age started)
Early intervention

CurrentPastNA
Notes
(e.g., age started)
IEP (Individualized Education Program)

CurrentPastNA
Notes
(e.g., age started)
504

CurrentPastNA
Notes
(e.g., age started)
FBA/BIP school behavior plan

CurrentPastNA
Notes
(e.g., age started)
Other school services or accommodations

CurrentPastNA
Notes
(e.g., age started)
Tutoring

CurrentPastNA
Notes
(e.g., age started)
Neurodevelopmental History
Is or was there reduced non-verbal communication such as pointing or gesturing?*
Is or was there reduced or atypical eye contact?*
Is or was there reduced affective expression or lack of smiling?*
Is or was there diminished interested in social interaction?*
Is or was there reduced responses when calling their name?*
Other indicators from 2-5 years of age
Is or was there reduced responses when calling their name?*
Is or was there a loss of language or words?*
Is or was there a limited use of words and phrases?*
Is or was there unusual, idiosyncratic or odd use of language and words?*
Is or was there a decreased interest and/or limited interaction with peers?*
Is or was there a restriction in imaginative play?*
Is or was there unusual preoccupations and/or interest in objects or parts of objects?*
Is or was there compulsions and/or a high degree of ritualistic behaviors? *
Developmental History*

UnknownNo developmental delays or concernsDifficult to soothe as infantGross motor delaysFine motor delaysExpressive language delaysReceptive language delaysSocial development delaysRepetitive behaviors or interestsOther autistic indicatorsEmotional problemsBehavioral problemsOther
Notes on Developmental History
Past Neurological, Psychiatric and Medical History
The patient’s neurological history is notable for:*

NoneAVMsCVA ischemicCVA hemorrhagicIschemic microvascular diseaseDementiaDemylenating disorder (atypical)Gullain-Barre SyndromeHemiparesis (left)Hemiparesis (right)Hemiplegia (left)Hemiplegia (right)MigrainesMeningitis (bacterial)Meningitis (viral)Multiple SclerosisMuscular DystrophyNeoplasms (primary)Neoplasms (secondary)New Choice (2)NeuropathyParkinson's DiseasePSPSeizuresSpinal Cord CompressionSpinal Cord InjuryTIAsOther
Patient Neurological History Additional information:
Family neurological history is notable for:*

Non-ContributoryUnknownEarly Dementia < 65 y/oParkinson’s DiseaseStrokeMultiple SclerosisOther
Family Neurological History Additional Information
The patient’s psychiatric history is notable for:*

NoneADHDAlcoholismAnorexiaAnxietyAutism Spectrum DisorderBehavior ProblemsBipolar DisorderBody Dysmorphic DisorderBulimiaDepression (episodic)Disruptive Mood Dysregulation Disorder (DMDD)DysthymiaIntellectual DisabilityLanguage DisorderLearning Disorder - readingLearning Disorder - writingLearning Disorder - mathOCDOppositional Defiant Disorder (ODD)Panic DisorderPTSDPersonality DisorderPhobiasPsychosis (brief)Psychosis (unspecified)Repetitive BehaviorsSensory Processing DisorderSchizophreniaSelective MutismSocial Pragmatic DifficultiesSomatization DisorderSuicidal DisordersSubstance AbuseOther
Is the patient non-verbal (not to be confused with selective mutism)?

YesNo
Does the patient have down syndrome or other moderate to severe intellectual disability?*

YesNo
Patient Psychiatric History Additional information
Family psychiatric history is notable for:*

NoneADHDAlcoholismAnorexiaAnxietyAutism Spectrum DisorderBehavior ProblemsBipolar DisorderBody Dysmorphic DisorderBulimiaDepression (episodic)Disruptive Mood Dysregulation Disorder (DMDD)DysthymiaIntellectual DisabilityLanguage DisorderLearning Disorder - readingLearning Disorder - writingLearning Disorder - mathOCDOppositional Defiant Disorder (ODD)Panic DisorderPTSDPersonality DisorderPhobiasPsychosis (brief)Psychosis (unspecified)Repetitive BehaviorsSensory Processing DisorderSchizophreniaSelective MutismSocial Pragmatic DifficultiesSomatization DisorderSuicidal DisordersSubstance AbuseOther
Does the patient have a history of sleep problem?*

YesNo
Notes
The patient's medical history is notable for:

None
Family medical history is notable for:

None
Cancer*

No prior cancer historyBreast CarcinomaColon CarcinomaEsophageal CarcinomaHodgkin's DiseasePrimary Liver CarcinomaLung CarcinomaMelanomaOvarian CarcinomaPancreatic CarcinomaProstate CarcinomaOther
Cardiac*

No prior cardiac historyAngina PectorisEsophageal CarcinomaArteriosclerotic Heart DiseaseAtrial FibrillationCADCardiac ArrestCardiomyopathyHypertensionOrthostatic HypotensionCHFPeripheral Vascular DiseaseBradycardiaMIRespiratory ArrestSyncopeTachycardiaOther
Dermatologic*

No prior dermatologic historyAcneAlopeciaDermatitisPressure soresCellulitisPsoriasisRosaceaScabiesWartsSunburnOther
Oral Disorders*

No prior oral disorderDysphagiaOropharyngeal basedEsophageal basedEdentulousGingivitisOther
ENT Disorders:*

No prior ENT disorderEaracheExternal OtitisHearing lossHerpes Zoster OticusLabyrinthitisLaryngitisMastoiditisMeniere’s DiseaseMyringitisNasal PolypsOtitis MediaOtosclerosisPerichondritisPositional VertigoPresbycusisRhinitisSinusitisVocal Cord ParalysisVocal Cord PolypsVocal Cord NodulesTonsillitisOther
GI Disorders*

No prior GI disorderColitisConstipationDiarrheaDiverticulosisDiverticulitisDysphagiaFecal ImpactionGastritisGERDGI BleedingHemorrhoidsHiatus HerniaIBSPancreatitis acutePancreatitis chronicEsophageal DiverticulaOther
Hepatic and Biliary*

No prior hepatic and biliary historyCholecystitisCholedocholithiasisCholelithiasisCirrhosis alcoholCirrhosis primaryFatty LiverFibrosisHepatitisHepatic GranulomasVascular lesionsOther
Hematologic*

No prior hematologic historyAnemiaBlood transfusionHodgkinsLeukemia acuteLeukemia chronicLeukopeniaLymphocytopeniaLymphomaPlatelet dysfunctionOther
Immunodeficiencies*

No prior immunodeficiencyAllergiesB cell deficiencyT cell deficiencyCombined B and T cellNo other immunodeficiencyOther
Infectious Disease*

No other infectious diseaseOther
Metabolic*

No prior metabolic disorderAmyloidosisAddison's diseaseCushing's syndromeElectrolyte imbalanceHyperlipidemiaHypoglycemiaNew ChoiceHypolipidemiaHyperpituitarismHypopituitarismHyperthyroidismHypothyroidismIDDMNIDDMPorphyriaRenal Disease end stageRenal InsufficiencyOther
Ophthalmologic*

No prior ophthalmologic concernsMacular degenerationGlaucomaNearsightedFarsightedWears glasses/contacts to correct visionBlindness LeftBlindness RightBlindness BilateralVitreous HemorrhagicCataractsEnucleation LeftEnucleation RightEnucleation BilateralOther
Pulmonary*

No prior pulmonary disorderAsthmaAtelectasis acuteAtelectasis chronicBronchiectasisBronchitis acuteBronchitis chronicCOPDEmphysemaLung AbscessPleural CalcificationPleural EffusionPleural FibrosisPleurisyPneumoniaPneumothoraxPulmonary EmbolismRespiratory DistressRespiratory FailureURIOther
Rheumatological*

No prior rheumatological disorderGoutOsteoarthritis (DJD)OsteomyelitisOsteoporosisPaget's DiseasePolymyalgiaPolymyositisRheumatoid ArthritisSclerodermaSLESjgren's SyndromeVasculitisSystemic SclerosisTemporal ArteritisWegner GranulomatosisOther
Status Post-Surgical List:*

No post-surgical historyAppendectomyCABGCholecystectomyColostomyGastrostomyHip ReplacementHysterectomyMastectomyIleostomyIntestinal BypassPacemaker ReplacementAortic Valve ReplacementOther
Has the patient experienced ongoing medical symptoms that doctors have not been able to identify the cause of these symptoms?*

YesNo
If yes, please explain below
Note: Include information on tests that were done that were inconclusive.
Note: Please email your relevant medical records to: pscreps@neuroci.com OR complete the NCBI's HIPPA Form on our website and we will request your records from these providers.

Please enter your digital signature below if you are the patient or the caregiver registering for the patient consenting to your evaluation.
Signature*

Clear
Submit this form by clicking the button below and you will receive an email to schedule your diagnostic appointments.

Should you wish for our Scheduling Team to manage your appointments, please contact them via email at pscreps@neuroci.com or call 973-601-0100. They will be happy to assist you.
Please verify that you are human*
Should be Empty:

Email: info@neuroci.com
Tel: (973) 601-0100
Fax: (973) 710-9152
Toll-Free: 1-888-NCI-9664

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Clinical Centers

Sleep Study and Treatment
Acquired and Traumatic Brain Injuries
Mind-Body Neuropsychiatric and Mental Health
Neurodevelopmental Disorders
Cognitive and Memory Disorders from Neurodegenerative Diseases

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