New Patient Screening

Update 4/1/2022:

Kinsler Psychology is currently accepting new patients for medication management and psychological testing services only and your estimated wait time for the intake session is 2-3 weeks. We are not accepting new patients for counseling services at this time, but we are compiling a waiting list and expect to resume accepting new patients in 2-3 months.

For all services, please complete the New Patient Screening. If you would like to be put on the waiting list for counseling services, please complete the form as well, and a member of the Front Office team will contact you when we are ready to schedule. Thank you for your patience.
New Patient Screening
Contact Information
Patient's Name *

First Name Last Name
Patient's Gender *

Female Male Transgender Non-binary/non-conforming Prefer not to respond
Patient's Primary Phone # *
Please enter a valid phone number.
If you are NOT the identified patient above, please state your full name, email, number and relationship to the patient.

0/100
Patient's Date of Birth *

Month Day Year
Patient's Email *
example@example.com
Patient's Address *

Street Address

APT#, Unit#, Suite#

City State / Province

Postal / Zip Code

Insurance Information
***Kinsler Psychology, LLC will only bill to the primary insurance, not secondary. Additionally we do NOT accept Medicare or Medicaid insurance.***
Insurance Company *
Subscriber Name *

First Name Last Name
Subscriber Date of Birth *

Month Day Year
Date
Member ID *
Insurance Card - Upload

Please attach an image of the front and back of your insurance card. This assists in verifying benefits and the billing process. You do not have to submit your insurance card at this time, but if you opt out of submitting it now, we will require it at a later time in the process.
Cancel of
Would you be using EAP (Employee Assistance Program) services? *

Yes No
***Dr. Kinsler & Associates, LLC, only accepts Aetna, Cigna, Optum, and Humana EAPs.***
If available, please provide the following information for EAP services:
EAP Authorization #:
What insurance is your EAP?

United/Optum Humana Aetna Cigna
How many sessions does your EAP allow?
What is the effective date of your EAP? (If known)

Month Day Year
Date
What is the expiration date of your EAP? (If known)

Month Day Year
Date
My EAP is a(n) EAP. I have blank sessions. My EAP effective date is Date and the expiration date is Date .

Contact Information