Miami Intake Inquiry Form

NESCA does not bill any insurance companies directly for evaluations. If you wish to seek partial reimbursement from your insurer, we will provide you with a detailed invoice (i.e. a superbill) at the conclusion of the evaluation.
Primary Contact First Name*
Primary Contact Middle Name
Primary Contact Last Name*
Preferred Method of Communication for Scheduling*

EmailPhone
Preferred Language

EnglishSpanishOther
Email*
example@example.com
Phone*
Street Address*
City/Town*
State*
Zip Code*
Patient's First Name*
Patient's Preferred Name (If Different from Legal Name)
Patient's Preferred Pronouns
Patient's Last Name*
Patient's Birthday*

MonthDayYear
Date
Has this Patient been seen at NESCA before? If yes, please indicate the service received and the approximate date of prior service.
Current School (indicate n/a if not in school)
Current Grade (indicate n/a if not in school)
Diagnoses (if any)*
How would you describe the patient's expressive verbal abilities*

NonverbalSingle word utterancesMostly 2-3 word or short phrasesUses simple sentencesUses compound and complex sentencesOther
Secondary Contact
Secondary Contact Email
example@example.com
Secondary Contact Phone
Who has Legal Custody or Guardianship of Patient?*

Primary ContactSecondary ContactPatientOther
If patient is a minor, please indicate Marital Status of Custodial Parents/Guardians. If patient is an adult, please indicate patient's Marital Status*

MarriedDivorcedOther
Referral Info
Referred by
Referred to
Reason for Referral: Please describe in detail your reasons for requesting evaluation and/or services at this specific time.*
Are you most interested in services that can be delivered:

In PersonRemotelyIn Person and/or Remotely
Which services are you interested in?*

Neuropsychological EvaluationComprehensive Diagnostic EvaluationNeurodevelopmental Evaluation (18 months-5 year olds)International EvaluationSchool Observations and ConsultationParent Coaching or ConsultationStudent or Adult Real-life Skills Coaching (Practical Life Skills)Student or Adult Executive Function Coaching
Please verify that you are human*
Should be Empty:

NESCA does not bill any insurance companies directly for evaluations. If you wish to seek partial reimbursement from your insurer, we will provide you with a detailed invoice (i.e. a superbill) at the conclusion of the evaluation.

Referral Info