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)

Member or policy number

Policy holder name

Insurance details are collected so our team can review coverage with you during your consultation. Please do not include sensitive medical information here.

Preferences

Preferred language

Caregiver preferences

Anything else we should know

Please do not include sensitive medical details in this form.

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