Client Intake

Client intake form

Share the care needs, insurance details, and preferences for the person who needs support. The more you tell us, the more prepared we are for your consultation.

Your details

Your full name

Relationship to the person needing care

Phone

About the person needing care

Their full name

Age range

County

City or town

Living situation

Mobility

Care needs

Select all the support that may be needed

When care should start

Schedule needed

Hours per week

Payment & insurance

How will care be paid for?

Insurance provider (if any)

Policy holder name (optional)

The insurance fields are optional. We ask only for the plan name and policy holder so our team knows what to check with you during your consultation. Please do not enter member or policy numbers here — we will collect those securely if and when they are needed.

Preferences

Preferred language

Caregiver preferences

Anything else we should know

Please do not include sensitive medical details in this form.

Privacy & health information. Please share only what is needed to start the conversation. Do not send diagnoses, medications, test results, or other detailed health records through this form. Read our Privacy Notice and Non-Discrimination Notice.

By checking this box, I agree to receive text messages from Premium United Health Care, L.L.C. related to intake follow-up, scheduling, and service-related communications at the phone number provided above. SMS frequency may vary. Message and data rates may apply. Reply HELP for assistance. Reply STOP to opt out of receiving text messages. Please review our Privacy Policy and Terms & Conditions.

Optional. Consent is not required to submit this form or to receive services.

I agree to be contacted by Premium United Healthcare about this intake form.