ADMISSION

Admission to Centers for Neurobehavioral Excellence is completed through a comprehensive application and assessment process which is utilized to determine each person’s individual needs and abilities to create the most effective and custom-tailored treatment plan.

To inquire, please contact us and complete our initial intake application below. All information provided will remain confidential and secure.

Name Of Client *

Home Address *

Date of Birth *

Medicaid # *

Social Security # *

Sex - please choose from dropdown below *

Birth City *

Birth Hospital *

Mother’s Name *

Mother’s Phone *

Mother’s Place of Work *

Mother’s Work Phone *

Mother’s Maiden Name *

Parents’ Marital Status - please choose from dropdown below *

Father’s Name *

Father’s Phone *

Father’s Place of Work *

Father’s Work Phone *

Legal Guardian Name

Legal Guardian Phone

Guardian Address

Current Residence of Client *

Home / Facility - please choose from dropdown below *

Physician’s Name *

Physician’s Phone *

Disability - please choose from dropdown below *

Ambulatory - please choose from dropdown below *

Medical Problems (including allergies) *

Developmental History (including developmental milestones, when the disability was discovered, how it manifested, and the causes) *

Recent Assessments (and dates) *

Diagnoses (including MR Level if known) *

Family History (other siblings, etc) *

Reasons for Requesting Placement *

Developmental Strengths (Abilities and Talents) *

Behavioral Management Skills and Coping Mechanisms (including what contexts they are used, when and why) *

By typing my name below, I am electronically signing my application. *

Date *

Name