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
*
Email
Phone
Preferred Language
English
Spanish
Other
Email
*
example@example.com
Phone
*
Format: (000) 000-0000.
Street Address
*
City/Town
*
State (enter "n/a" if not applicable
*
Zip Code (enter "n/a" if not applicable
*
Country
*
Patient's First Name
*
Patient's Preferred Name (If Different from Legal Name)
Patient's Preferred Pronouns
Patient's Last Name
*
Patient's Birthday
*
/
Month
/
Day
Year
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
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Nonverbal
Single word utterances
Mostly 2-3 word or short phrases
Uses simple sentences
Uses compound and complex sentences
Other
Secondary Contact
Secondary Contact Email
example@example.com
Secondary Contact Phone
Format: (000) 000-0000.
Who has Legal Custody or Guardianship of Patient?
*
Primary Contact
Secondary Contact
Patient
Other
If patient is a minor, please indicate Marital Status of Custodial Parents/Guardians. If patient is an adult, please indicate patient's Marital Status
*
Married
Divorced
Other
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 Person
Remotely
In Person and/or Remotely
Which services are you interested in?
*
Neuropsychological Evaluation
Comprehensive Diagnostic Evaluation
Neurodevelopmental Evaluation (18 months-5 year olds)
International Evaluation
School Observations and Consultation
Parent Coaching or Consultation
Student or Adult Real-life Skills Coaching (Practical Life Skills)
Student or Adult Executive Function Coaching
Please verify that you are human
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