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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 each question on this patient registration and history form in sequential order. 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.
Informed Consent for Treatment at NCBI

Purpose of the Informed Consent
To inform patients and their guardians of the types of treatments offered at NCBI, the
clinicians providing these treatments as well as the potential risks and benefits from
treatments.

Treatments:
A variety of treatments are offered at NCBI by different clinicians. These treatments include:
- Psychological therapies that are provided by clinical psychologists and
  psychotherapists via play therapy for children and talk-based therapy for older
  children, adolescents, and adults individually and/or in groups.
- Behavioral therapy is another treatment that aims to change a patient’s behavioral
  problems either directly with the patient, and/or the patient’s caregiver. Applied
  behavioral analysis (ABA) is a form of behavioral therapy that focuses more at
  enhancing the patient’s functioning as opposed to only addressing behavioral
  problems.
- Rehabilitation that includes cognitive rehab interventions, with and without non-
  invasive neuromodulation (use of waves), speech-language and learning disability
  therapy as well as occupational therapy.
- Medication therapy is the use of different classes of medication to treat cognitive,
  behavioral, emotional and psychosis symptoms.
- Non-invasive neuromodulation interventions include the use of various
  neuromodulation procedures using magnetic coils (transcranial magnetic
  stimulation/TMS) or various waves (e.g., transcranial alternating current / tACS) to
  enhance cognitive functioning or reduce psychiatric symptoms such as anxiety,
  depression, OCD, addiction as well as pain.
- Treatment programs are also offered.
Clinicians:
The clinical staff at NCBI includes clinical (neuro) psychologists, physicians, physician-
assistants, advance practicing nurse clinicians, psychotherapists and rehab therapists as well
as clinical technicians. You may receive treatment from one or more members of the clinical
staff.

What you will be asked to do in the treatment:
Your treating clinician(s) will explain your role in receiving treatments that you have consented
to receive for yourself or your child or other individual who is not able to give their own written
informed consent. You may be asked to sign an additional informed consent specific to the
treatment(s) you may be receiving.

Risks, discomforts and Benefits:
Your individual treating clinician(s) will review with you the potential risks from the
treatment(s) you may receive as well as potential benefits from one or more treatments for
your symptoms, deficits, syndrome, disorder and/or illness.

Voluntary participation:
Your participation is all treatments is voluntary. Your treating clinician(s) will discuss with your treatment options and the various phases of treatment.

Withdrawal from the study:
You may stop participating in treatment at any time, for any reason, if you so decide. Your decision to stop participating, will not affect your relationship with the treating clinician(s) at NCBI.

Confidentiality:
All data related to your treatment(s), for example, progress notes, are stored in your
confidential individual electronic medical records (EMR). The clinical and administrative staff at NCBI has access to your EMR. If you enter treatment and prefer that only your treating clinician have access to your treatment notes, please discuss that option with your treating clinician(s). That progress note or other medical records can be restricted to specific members of your treatment team. Your treatment records are kept confidential up to 7 years from the time you stop treatment and up to age 23 for pediatric patients. Your records can be sent to you at any time.

Questions about your treatment:
Please discuss with your treating clinician(s) any questions you may have prior or during your treatment(s).

Signatures:
I am not waiving any of my legal rights by signing this form. My signature below indicates my consent to receive treatment(s) and I will discuss with my individual treating clinician(s) any additional concerns.
Patient Status
Patient's Legal Name

First NameLast Name
A parent/caretaker is filling out this form on the patient's behalf
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
2 digit month, 2 digit day, 4 digit yearDate
Confirm Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DOB does not match!
Gender at Birth
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 18 years old or older AND has New Jersey Medicaid as their primary insurance? (ONLY ANSWER YES IF BOTH ARE TRUE)
The patient interested in:
Patient or Primary Caregiver’s Mobile Phone Number
Format: 000 000 0000 .
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.Format: (000) 000-0000.
Referring Physician
Please ensure we receive your relevant medical records ahead of any appointments.
Referring Physician Office Location
Referring Physician Office Phone Number
Health Insurance
Primary Insurance Company
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
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:
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?
Does the patient have access to a personal computer, laptop and/or tablet with a camera and microphone?
Can the patient navigate a personal computer independently?
Please indicate if this testing is to assess for
Are the patient’s expressive language abilities intact? ie Can they use words to verbally communicate at an age appropriate level? Answer “Yes” if the patient is able to communicate verbally, even if they have speech/language delays, articulation problems, limited vocabulary, or difficulty expressing complex ideas. Select “No” only if the patient is nonverbal or has very limited functional spoken language.
If expressive language abilities are impaired, does the patient have significant difficulty communicating basic needs using even a single word or short phrase?
Does the patient have Down Syndrome or an established IQ of 65 or less?
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
Would you like to receive email updates about NCBI?
I would like to be contacted if an earlier appointment becomes available due to a cancellation or reschedule.
Patient History Form
I. Patient Information
Race
Ethnicity
Handedness

Other
If left-handed: Other left-handed family members?
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 current primary language?
If Other, please specify
What is the patient’s present receptive language abilities?
What is the patient's present expressive language abilities?
Patient Educational Information
What is the patient's highest or current level of education?
Current Grade (for current students only)
Skipped a grade?
If grade(s) were skipped, which?
Repeated a grade?
If grade(s) were repeated, which?
Is the patient receiving or has the patient ever received an IEP or special education related services?
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):
Please explain
Additional info:
Is the assessment related to a disability application or ongoing disability claim?
Is the assessment in relation to legal or financial matters (e.g., pending litigation, financial benefit considerations)
Is the patient seeking solely psychotherapy services, without an interest in neuropsychological assessment?
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.
Treatment/Therapy Type
Psychotropics
Notes
(e.g., age started)
Is the patient receiving psychotherapy?
Notes
(e.g., age started)
Has the patient received psychotherapy in the past?
Notes
(e.g., age started)
School counseling
Notes
(e.g., age started)
Has the patient had any past psychiatric hospitalizations?
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)
Notes
(e.g., age started)
Speech therapy
Notes
(e.g., age started)
Occupational therapy
Notes
(e.g., age started)
Physical therapy
Notes
(e.g., age started)
Cognitive rehabilitation
Notes
(e.g., age started)
ABA or behavioral therapy
Notes
(e.g., age started)
Social skills group
Notes
(e.g., age started)
Early intervention
Notes
(e.g., age started)
IEP (Individualized Education Program)
Notes
(e.g., age started)
504
Notes
(e.g., age started)
FBA/BIP school behavior plan
Notes
(e.g., age started)
Other school services or accommodations
Notes
(e.g., age started)
Tutoring
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

Other
Notes on Developmental History
Past Neurological, Psychiatric and Medical History
The patient’s neurological history is notable for:

Other
Patient Neurological History Additional information:
Family neurological history is notable for:

Other
Family Neurological History Additional Information
The patient’s psychiatric history is notable for:

Other
Is the patient non-verbal (not to be confused with selective mutism)?
Does the patient have down syndrome or other moderate to severe intellectual disability?
Patient Psychiatric History Additional information
Family psychiatric history is notable for:
Does the patient have a history of sleep problem?
Notes
Patient's Medical History
The patient's medical history is notable for:
Cancer

Other
Cardiac

Other
Dermatologic

Other
Oral Disorders

Other
ENT Disorders:

Other
GI Disorders

Other
Hepatic and Biliary

Other
Hematologic

Other
Immunodeficiencies

Other
Infectious Disease

Other
Metabolic

Other
Ophthalmologic

Other
Pulmonary

Other
Rheumatological

Other
Status Post-Surgical List:

Other
Family medical history is notable for:
Additional information about the family medical history
Has the patient experienced ongoing medical symptoms that doctors have not been able to identify the cause of these symptoms?
If yes, please explain below
Note: Include information on tests that were done that were inconclusive.
Family Medical History
Interpreting Clinician
Pass or Review
Please review all the information entered and correct any mistakes before submitting this form.
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
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
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Email: info@neuroci.com
Tel: (973) 601-0100
Fax: (973) 710-9152
Toll-Free: 1-888-NCI-9664

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