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
Legal Name of Child/Adolescent*
First Last
Child/Adolescent's Date of Birth*
MM slash DD slash YYYY
Age*
Insurance Information
Insurance Company*
Policy Holder Name*
Social Security #*
Date of Birth*
MM slash DD slash YYYY
Phone*
Member ID*
Group ID*
Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian #1*
Parent/Guardian #1*
First Last
Email*
Phone*
Parent/Guardian #2
Parent/Guardian #2
First Last
Email
Phone
Patient Background
Individualized Education Programs (IEP)*
- Yes
- No
Autism Diagnosis*
- Yes
- No
Doctor's Name*
Diagnosis Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.