Kincare Behavioral Health

Intake Form

Confidentiality Notice:

HIPAA mandates that all Protected Health Information(PHI) that is transmitted, stored, or accessed electronically be encrypted.

*INFORMATION PROVIDED ON THIS PAGE WILL NOT BE KEPT IN YOUR PERSONNEL FILE*

  • Child's Information

  • MM slash DD slash YYYY
  • Insurance Information

  • MM slash DD slash YYYY
  • Parent/Guardian #1*
  • Parent/Guardian #2
  • Patient Background

  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.