New Patient Screening

Update 5/1/2023:

Kinsler Psychology

At Kinsler Psychology, we have a variety of providers with decades of experience who can provide medication management services, counseling services, couples counseling services, family counseling services as well as psychological testing services. Please keep in mind, we do not have psychiatrists who are taking new patients in our office, so if you are interested in multiple services, you will need to see different providers for each service. We do not offer services involving the completion of FMLA or Short Term Disability paperwork. We accept all major insurances except for Medicaid & Medicare at our practice. For patients who have Blue Cross Blue Shield insurance, please keep in mind that your insurance has put a hold on credentialing new providers and therefore availability is limited at our practice as only a few of our providers are licensed with Blue Cross.

Once you have filled out the New Patient Screening, you will be automatically added to our waitlist. We will create a chart for you in our EHR system and check your insurance benefits. Next we will reach out to you via email with a request for additional paperwork. While we know filling out paperwork is everyone's least favorite part of becoming a new patient, we assure you that it is necessary to ensure we can provide you the best services possible. Once you have filled out the second round of paperwork, we will reach out to you to schedule your new patient intake appointment. Please allow 72 business hours between each step as we are inundated with new patient requests daily. Rest assured, as we recognize the rise in need for mental health services these days, we are fully committed to doing our part in helping as many people as we can.

Please complete the New Patient Screening paperwork and provide a copy of your insurance card (front & back). Images of your insurance card are necessary for the verification of benefits and billing process. Please set aside at least 15 minutes to complete our paperwork as the information you provide in the form will be reviewed by Dr. Kinsler herself in order to assign you to the provider that is best suited for your needs.
New Patient Screening
Contact Information
Patient's Name*

First NameLast Name
Patient's Gender*

FemaleMaleTransgenderNon-binary/non-conformingPrefer not to respond
Patient's Birth Sex*

FemaleMale
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*

MonthDayYear
Patient's Email*
example@example.com
Patient's Address*

Street Address

APT#, Unit#, Suite#

CityState / Province

Postal / Zip Code

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

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
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.
Cancelof
Would you be using EAP (Employee Assistance Program) services?*

YesNo
***Kinsler Psychology, only accepts Aetna, Cigna, Optum, and Humana EAPs.***
If available, please provide the following information for EAP services. Additionally please provide your insurance ID information in the above fields
EAP Authorization #:
What insurance is your EAP?

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

MonthDayYear
Date
What is the expiration date of your EAP? (If known)

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

New Patient Screening

Contact Information

Patient Information

Insurance Information

Additional Information