Admission Inquiry Form

Our Admission Inquiry Form may be helpful in showing you the type of information that will be necessary for referral sources to provide during the admission process. In addition, the information on this form may provide either an initial prequalification or a determination that NECC is not a proper fit. In this way, parents/legal guardians may be able to determine if they should proceed with the more in-depth admission process.

Please Read Before Submitting:

Completing and submitting this form DOES NOT officially begin the admission process; this is an inquiry only to provide us with enough information in advance to provide you with a more informed response.


 

* Required fields

Child's Name:
Date of Birth:
Diagnosis:
Chronic Illnesses:
Parents' Name:
Address:
Phone:
E-mail: *

1. What area of the program are you interested in?



2. Does your school system support an out-of-district placement?
3. How does your child communicate?
4. What are your child's academic abilities?
5. Do you have any concerns with your child’s behavior? If so, please explain:
6. Is your child on any medications?
7. Is your child on a special/restricted diet?
8. Has your child received any alternative treatments? (i.e. floortime, auditory integration, secretin therapy)
9. How did you learn about NECC?