New Patient Screening

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Update 6/13/2022:

Kinsler Psychology is currently accepting new patients for medication management, psychological testing services, and counseling.

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.

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New Patient Screening

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Contact Information

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Patient's Name *

First Name Last Name
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Patient's Gender *

Female Male Transgender Non-binary/non-conforming Prefer not to respond
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Patient's Birth Sex *

Female Male
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Patient's Primary Phone # *
Please enter a valid phone number. acc.options is not iterable
If you are NOT the identified patient above, please state your full name, email, number and relationship to the patient.

0/100

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Patient's Date of Birth *

Month Day Year

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Patient's Email *
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Patient's Address *

Street Address

APT#, Unit#, Suite#

City State / Province

Postal / Zip Code

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Insurance Information

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

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Insurance Company *
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Subscriber Name *

First Name Last Name
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Subscriber Date of Birth *

Month Day Year
Date
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Member ID *
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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
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Would you be using EAP (Employee Assistance Program) services? *

Yes No
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***Dr. Kinsler & Associates, LLC, only accepts Aetna, Cigna, Optum, and Humana EAPs.***

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If available, please provide the following information for EAP services. Additionally please provide your insurance ID information in the above fields

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EAP Authorization #:
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What insurance is your EAP?

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

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

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

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New Patient Screening

Contact Information

Patient Information

Insurance Information

Additional Information