Diagnostic Evaluation Pre-Screening Information

Autism Evaluating Appointment Information for Kind Behavioral Health's Psychological Partner, Insight Carolinas
Kind Behavioral Health is excited to have partnered with Insight Carolinas to offer Autism Evaluations to the North Carolina community! Insight Carolinas is seeing patients at our KBH facilities for ages 18 months-7yrs old.

If you need testing for concerns other than ASD (ADHD, mood, etc.) or if your child is over the age of 7, please book directly with Insight Carolinas at https://www.insightcarolinas.com/referrals.

Insight Carolinas is currently accepting virtual pre-screening appointments for children without an official Autism Diagnosis. Virtual appointments on average take 30-45mins and will require both parent and child to be present for the appointment. Once the pre-screening appointment is completed, the Insights team will schedule an appointment for an in-person evaluation at one of our Kind Behavioral Health locations (if applicable).

Insight Carolinas is currently in-network with the following insurance carriers:
- Aetna
- Anthem
- BCBS
- Medcost
- Medicaid-United Health Care Community Plan
- Medicaid-Partners
- Medicaid- Alliance
- Medicaid-Carolina Complete Health
- Medicaid-Healthy Blue
- Medicaid-AmeriHealth
- Medicaid-Trillium
If your insurance provider is not listed above, Insight Carolinas does offer private pay options for pre-screening and evaluation appointments. If your family would like to complete an appointment using the private pay option, please check the private pay option and a team member will reach out with details.
By checking this box, you are acknowledging that you have read and understand the information above, and would like to proceed with scheduling an appointment with the Insight Carolinas evaluating team.*

Yes, I acknowledge and would like to proceed

Insight Carolinas Appointment Overview

Please Read the Information Below in its entirity:
Step 1. Fill out the Jotform.

Step 2. Once the Jotform is completed, we will check your insurance. After verification of benefits is done, we will send you a text from 704-251-9084.

Step 3. If we are able to verify in-network active benefits for both the virtual prescreener and full testing (if warranted), we will send you a Welcome email to the patient portal, which will have the following forms:
- Parent History of Child Form
- Client Insurance Form
- Consent for Services
- Notice of Privacy Practices
- Client Contacts Form
- Insight Carolinas Policies and Procedures
- Payment Authorization Form
- We will also send you a take-home assessment via email from Pearson Assessments or QGlobal. Please fill this out as well.
Step 4. Once all forms are completed, contact us via text or call at 704-251-9084, or email us at info@insightcarolinas.com. We will reach out to you to schedule a virtual prescreener appointment.

IF FULL TESTING IS WARRANTED AFTER THE VIRTUAL PRESCREENER:

Our psychologist will schedule a tentative appointment.
We will send out some more take-home assessments that will come from Pearson/QGlobal, PAR/PariConnect, and WPS Publish.
For clients 16 and older, please check the patient portal for additional assessments.
Once these are completed, your appointment will be confirmed.

Thank you for completing your application! Someone from Insight Carolinas scheduling staff will be reaching out to your family shortly with availability of the next pre-screening appointments. Be on the look out for the following phone number/email address reaching out in the upcoming days:

Email: info@insightcarolinas.com

Phone: 704-251-9084
What is your preferred mode of communication?

TextCallEmail
Additionally, we ask that families complete a medical release form. This allows Insight Carolinas to share the appointment information and evaluation results to KBH.

Please click NEXT to complete this form.
Authorization for Release of Client Records & Information
Client's Name

First NameLast Name
Client's Date of Birth

MonthDayYear
Date
Parent/Guardian's Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
I hereby Authorize Kind Behavioral Health to:

Obtain records from Insight Carolinas following the evaluation appointmentRelease records to Insight Carolinas following the evaluation appointmentI do not consent to information being shared with Kind Behavioral Health
Per Kind Behavioral Health's record release policy, we will only release these records via a secure, HIPAA compliant OneDrive folder.

I understand that:
- This authorization to release information will remain in effect until ___________(Date). In the event that an expiry date is not provided, I understand that this authorization will remain in place indefinitely until the point of my written request to remove such consent.
- I may revoke this authorization at any time by notifying [Kind Behavioral Health] in writing, and this authorization will cease to be effective on the date notified except to the extent action has already been taken in reliance upon it.
- The information will be handled confidentially in compliance with all applicable federal laws.
- This consent does not permit the recipient to authorize release of my information to a third party.
- My refusal to sign this Authorization will not jeopardize my child’s right to obtain present or future treatment except where disclosure of the Information is necessary for the treatment
By Signing below, I acknowledge that I have read and understand this Authorization.*

Powered by Jotform SignClear
Phone Number
Please enter a valid phone number.
Email
example@example.com
Insurance Provider
United HealthCare, BCBS, Medicaid, etc.
Insurance Subscriber's Name*

First NameLast Name
Insurance Member ID*
Insurance Subscriber's Date of Birth *

MonthDayYear
Questions/Comments for provider:
Should be Empty:

Autism Evaluating Appointment Information for Kind Behavioral Health's Psychological Partner, Insight Carolinas

Insight Carolinas Appointment Overview

Diagnostic Evaluation Pre-Screening Information

Authorization for Release of Client Records & Information